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SAN JOAQUIN COUNTY <br />0 ENVIRONMENTAL HEALTH DEPAR <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sivov.org/ehd <br />/� ill f P�1?i�di ��i,�i'�'►'1 ...�" - - <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />1,5ol (,I> t=KS CITY STATE ZIP CODE AT <br />CA <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />e T e✓ l l'1 I.. -Vim.- Ge t.G[rr. e. <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />C;25,3s br ObfV&,( _ x.33 <br />CI7Y STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRAC <br />9 <br />d c- �� / , , C'; Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) 2002 2003 1 2004 1 2005 2006 2007 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 i£ New J- I <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S24.00/ FArn rTv <br />in <br />TANK ID # (s) : <br />TEMPORARY CL <br />(Plan Review and <br />TANK ID # (s) : <br />INSTALLATION F <br />(Plan Check and C <br />TANK ID # (s) : <br />FEE = $294 / TANK <br /># TANKS X $294 = I $ <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />CHECK FEE = $784 / FACILITY I $ <br />OFFICE USE ONLY <br />