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m s u.v YArIVI iYYWAXI a MiALTJ3.UEPARTMENT <br /> 600 East Main Street,Stockton,CA 9520 <br /> AMwkone'(209)468-342OFfi=(209)468-3433Wel-okmn�---orgichd <br /> FACILITY NAME FACILITY CONTACT E <br /> s <br /> r <br /> FACILITYADDRESS SITE E#WWI TH CODE <br /> CITY STATE ZIP CORE <br /> • #AF TANKS AT SITE <br /> CA <br /> APPLICANTsILLWGNAME API'LtcANT CONTACT NAME <br /> Ll/ <br /> APPLICANT MAILING ADDRESS •APPLICANT PHONE#WITH AREA CODE. <br /> 25.. <br /> :CITY STATE ZIP CODE CIRCLE WORK TO BE DONE <br /> CO ICC# <br /> Closure InstaBatlon Re Retrofit <br /> ACi�VE FACILITY <br /> $500.FEE.INCLUDESFAGILITY FEE+.1TANK(ZO( 2t)p7) 20� 2007- 2008 2009'` 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+.'I TANK(2006-2011) <br /> $125 PER.TANKAFTER FRSTTANK <br /> - TANK.PECdAt_TYASSESSED :.: - <br /> TANKSURCt TARGE=$15/TANK <br /> :STATE SURC1 TARGE FOR FACII RIES NOT ALREADY ON INVENTORY 19A CUPA PROGRAM X49.00/FACILRY <br /> • .P.ERA�ANENfT CLOSURE . <br /> Removal or Permitted Ckm i e in Place <br /> [ANK-ID-# $ CLOSURE FEE_$375/TANK #TANKS X$375= <br /> tEMPORARY CLOSURE <br /> F?(an Review mdi ons <br /> TAiViC iD (sj: TEMPORARY CLOSURE FEE_$375Y FACILITY $ <br /> INSTALLATIC)N PLAN CHECK - - - <br /> ati-Cheekand'Constiucttoh tris_.._ _ <br /> _ .. . -PIM GHECK.FEF=_$I000fFF4CIL1]Y . <br /> RERAIR PLAN ---- <br /> C ECK <br /> TANK ID#(s) <br /> -- <br /> - Isn -told°std - ----•- - ------- -- <br /> • <br /> tAlt_ AIRfEE 75 _._ __ <br /> crorttafnrr�nt,ed <br /> TPtANSFER FEE $25_.: _ _ ' <br /> 1�d3UNr�TItiN <br /> $'125/WOtJR .. . . <br /> EE`�i GA UATJONFEE a$1?5%HOURR—OBLVEURIMM - ,. ..... ... _. ...---.._.w <br /> .... <br /> SAMPLING INSPECTION FEE <br /> ON THE 5126 HOURLY RATE TBIIE TNkT IXCEEDS FEES PAS WB L BE BILLEp TO APPLICANT - — — <br /> r <br /> AM0Ij9MLWDtJE <br /> t <br /> SrRViGER15QtiEST#t FACIGIiY'ID AMOUNT RECEIVED <br /> CHECK# RECEIVED BY ' AATE RECEIVED <br /> -EH'23 D32(REVIgEp 08/1111 by KFS• i <br />