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12/02/2008 14:42 FAX 9163712540 BZMAINT 0 005 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DRPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Flo (209)468-3433 Web:WvLwg!3Y•or¢/d <br /> FAC141TY CONTACT NAME <br /> FACILITY NAME D V7 H G I V L— <br /> SITE PHONE N WITH AREA---- <br /> f CILITY <br /> ODEFACILITY ADDRESS Q /7 ' <br /> _ ^7 1f 3 2 <br /> 4 9i:5 STATE ZIP CODE 6 1$OP7TJA KB AT SITE <br /> CITU S 1 3 <br /> S-70CP"Ib CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> IMS nM Jiv <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE ak W{TN AREA CODE <br /> 55 S �kJ � 11 Zip <br /> c), L(3 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE ONE CONTRACTORICC 11 <br /> S`► 70N Closure Installation on epair et <br /> ACTIVE FACILITY �n <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007)ER $ <br /> $125 PERI <br /> AFTER FIRST TANK 1 TANK(2008) <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANKSURCHARGE= 15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM m$24-001 FACILITY <br /> pERMANENTCLOSURE $ <br /> TANK ID# s : <br /> Removal or Perri Closure in Placa <br /> CLOSURE FEE=$284/TANK 1!TANKS X 284 <br /> TEMPORARY CLOSURE <br /> Plan Review and Ina ons $ <br /> TANK 10 0(s): TEMPORARY CLOSURE FEE R 5294/FACILITY <br /> INSTALLATION PLAN CNECK $ <br /> Plan CheGc end ConsWdlon Ina ee0ons <br /> TANK ID#(s) <br /> PLAN CHECK FEE $7841 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID A(9); $ <br /> TANK RETROFIT REPAIR FEE =$2941 FACILITY (es 19 r oidt sum suipment,cold starts,EVR upgrades, <br /> PIPING REPAIR FEE $2841 FACILITY use for i In Undi neer containment,eot. <br /> MISCELLANEOUS $ <br /> TRANSFER FEE = 20 $ <br /> CONSULTATION FEE = 981 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE • 981 HOUR $ <br /> SAMPLING INSPECTION FEE • 881 HOUR <br /> ALL FEES AR BASED ON THE it HOURLY RATE. ME THAT CEED FfiEa PAID WILL BE BILLED TO PPUCANY. <br /> OFFICE USE ONLY <br /> SERVICE REgUE6T p PACILITV ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RE <br /> SR <br /> EH 23 032(REVISED 1213111 <br />