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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave„ Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si ov org/ehd <br />Y NAME <br />FACILITY CONTACT NAME <br />/IJ.1iS �� <br />Y ADDRESS <br />STA <br />f'yY• CA <br />BIL <br />CITY STATE �Ip <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $151 TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON <br />/(P�di�ONE VI FH AREA CODE ,r <br />49 Cf <br />TO BE <br />Closure <br />0081 2009 2010 2011 2012 <br />IN A CUPA <br />CONTRACTOR ICC # <br />iLITY <br />OFFICE USE ONLY <br />