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08/21/2006 15:54 4640138 <br /> ENVIRC-SENTAL HEALTH PAGE 01 <br /> 0SAN JOAQM COUNTY 0 <br /> ,NvRONMETfCA LHEALTH DEPARTMEN <br /> 304 East Weber Avenue.3 Fioor�9t 4G8 343Web:www�•Qt.B1r—� <br /> 2-2709 <br /> Telephone:(209)468-3420 Fair(5*flow):( ) <br /> FACILITY CONTACT NAME <br /> FAC ITY NAME —a <br /> U SITE PIIO'HE a WITH AREA CODE <br /> FACILITY gpDRESS <br /> CO S OF TANKS AT SITE <br /> STATE <br /> CITY <; - <br /> Ca 1F� <br /> NAIVE APPLICANT CONTACT NAME <br /> APPY SCANT BtaLLWG <br /> APPLICANT M p1LING AfIDRESS APPLICANT PIIi7NE f WITH AREA CODE <br /> CITY STATE 2115 GODS CIRCLE WORK TO RF DONE CONTRACTOR CC 0 <br /> Clv9ure Inst9Safion Repair Ret-flt <br /> ACTIVE FACILITY <br /> 2D01 2002 2003 2004 2005 2006 <br /> $SM FEE INCLUDES FACILITY FEE+1 TANK $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASST SSED $ <br /> TANK SURCHARGE_$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM='324.441 FACILITY <br /> P RMANENT CLOSURE $ <br /> Remorral <br /> of Permitted CWufe in Place it TAWS%$285 <br /> CLOSURE FEE'S285I TANK <br /> TANK 10# s <br /> TEMPORARY CLOSURE $ <br /> plan REvlaw and In GSons <br /> TEMPORARY CLOSURE FEE=$2851 FACILITY <br /> TANK ID II(s)i <br /> INSTALLATION PIJW CHECK $ <br /> Plan Check and Constmclion In coons pLAN CHECK FEE=57601 FACILITY <br /> TANK ID 0(s) <br /> REPAIR PLAN CHECK <br /> TANK ID 9 s <br /> TANK RETROFIT REPAIR PEE =$2551 FACILITY use for fna Mlodn: <br /> 1 s Ill t7udcsls.tank sum ,misC, $ <br /> 'REPAIR FEE =5285!FACILITY <br /> use for ping,under er containment.cd. <br /> MISCELLANEOUS $ <br /> $ <br /> TRANSFER FEE ' 122 <br /> CONSULTATION FEE = S 351 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE S 951}LOUR <br /> AMPLING INSPETN FEE nM <br /> = S 951 HOUR <br /> SAM <br /> E FEES APED C ) THE its NbURLY RATE. rz THAT <br /> p(GEEt}S t t.t:5 PAID WILL <br /> SCIOBE Ett LEra Ta AppL1CAMT. <br /> OFFICE USE ONLY pNp�Irr RECEIVED CHECK M RECEIVED BY BATE REGEiVED <br /> "RVICE REQUEST 9 FACILITY M <br /> SR <br /> EN 22 032(REViSED OV2510e1 <br />