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SAN JOAQUIN COUNTY <br />N4041ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3'u Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (Sr" floor): (209) 468-3433 Web: www.sigov.or /e ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />\JSA CCtots <br />SLk JOvt+s <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />.>na Mau, a Imo. <br />cl 946- qa_8-;'- <br />CITY I <br />STATE <br />ZIP CODE <br />I # OF TANKS AT SITE <br />5ts�k�av► <br />CA <br />I' <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Se� S{AtzaolS Si -" <br />Li4A w 4 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />M QJ%u.vt Ave, <br />*% a13 -%03Q <br />CITY _-.. - - - <br />STATE <br />.. LP CODE <br />.CIRCLE WORK: TO BE DONE <br />CONTRACTOR IICG# <br />$ <br />Closure lnstallafion4jRar etroit <br />1 as j(OV— <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $285 / TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 95 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 95/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <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 />PERMANENT CLOSURE <br />Removal or Permitted Closure In Place <br />TANK ID # (s): <br />CLOSURE FEE = $285 / TANK <br /># TANKS X $285 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s):�. - - - <br />TEMPORARY CLOSURE FEE _ $285 / FACILITY <br />REPAIR PLAN CHECK <br />I FACILITY ID <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $285 / FACILITY use for monitoring equipment, s ill buckets, tank sumps, misc.)$agS- <br />7oATE RECEIVED <br />PIPING REPAIR FEE = $285 / FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />MISCELLANEOUS <br />I FACILITY ID <br />I AMOUNT RECEIVEDCHECK <br />$ <br />TRANSFER FEE _ $ 20 - - <br />7oATE RECEIVED <br />SR <br />$ <br />CONSULTATION FEE = $ 95/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 95 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 95/ HOUR <br />ALL rOCe NRL PM CV VN 1 nL YJa nwnu RAI C. umc INA I uLCCw rCCJ rwV WILL oe DILLcu IV ArrubAN I. <br />OFFICE USE ONLY <br />SERVICE REQUEST# <br />I FACILITY ID <br />I AMOUNT RECEIVEDCHECK <br /># <br />RECEIVED BY <br />7oATE RECEIVED <br />SR <br />CR LJ WL tRCY1JCV V,/LiIV/) <br />