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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 Mst Weber Avenue, 30 Floor, Stockton, CA 952008 <br />Telephone. (209) 468-3420 Fax (P floor): (209) 468-3433 Web: www.si¢ov.ore/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />U S A 10G a-& Sid a <br />MkeU y 3l <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />.113a Mav� oso. `Kc� <br />a0j 946-4a8a. <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />�tccl� Eos <br />CA <br />R 5 a o r <br />4 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />S'wy i:( -e �rto fLON �Ia Ls Sµ L • <br />L02 l+4 ALN <br />APPLICANT MAILING ADDRESS <br />APPLICANT P ONE # WITH AREA CODE <br />ta%b QVLVIVI Aut, <br />riU$ (3-�OOc�4 <br />CINC - <br />-STATE <br />ZIP. CODE <br />.CIRCLE WORK :TO.BE DONE <br />CONTRACTOR ICC.# <br />` <br />So -v.. qBs-Q.. <br />CA <br />g0la— <br />Closure Installation Gio Retrofit <br />- <br />5-.,SOSIOV—Lrr <br />ACTIVE FACILITY <br />TANK ID # (a): <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />007 <br />2 <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$15/TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (a): <br />CLOSURE FEE _ $285 [TANK <br /># TANKS X $285 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (a)Y. - - - <br />TEMPORARY CLOSURE FEE - $285/ FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (a): <br />$ <br />TANK RETROFIT REPAIR FEE = $285 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, misc.)7$274. <br />$ <br />PIPING REPAIR FEE = $285 / FACILITY use for i in , under-dis enser containment, act. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 95/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 95 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 95/ HOUR <br />eI . eco. Doc neeen nu ruc me unuery DATE T,AIr T.,.T ..,...�.... �..�.. ...... ...... __ _... __ __ . __.._ _ _. <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 01/29107) <br />