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05713/2008 TUE 14:10 PAX 20 0 <br />433 SJC 281) ®005/007 <br />SAN J'OAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARlwv - , r <br />600 East Main Street, Stockton, CA 95202.3029 <br />Telephone: (209) 468-3420 ,Fax: (209) 468-3433 Web: www.sjgov.oxgJehd <br />FACILITY -NAME <br />FACILITY CONTACT NAME <br />�� t� <br />1 YL C <br />FACILITY ADDRESS <br />SITEPHOWE # WITH AREA CODE <br />APPLICANT WITH AREA CODE <br />$ <br />CITY I STATE <br />ZIP CODE OF TANKS AT SITE <br />- cASU <br />STATE <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />�� t� <br />c• i"'i •�'YYk.�-tnr <br />J�.�i;.C.- a�'1C�t 'tu'".r�'s er <br />APPLICANT MAILING ADDRESS <br />APPLICANT WITH AREA CODE <br />$ <br />$500 FEE.INCLUDES FACILITY FEE + i TAMC (2002-2007) <br />/PHONE <br />/$ <br />CITY <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC 9 <br />/ <br />.� ci �i(• % r�' » <br />t l71 <br />`i�":2 V -r Cbsure Installation Ream Retrofit <br />AG I IM f-ALALI UT <br />TANK ID #F s <br />2002 <br />2003 2004 2005 <br />2006 <br />2007 <br />$ <br />$500 FEE.INCLUDES FACILITY FEE + i TAMC (2002-2007) <br />$ <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2000 & New <br />$ <br />Installs as of 811107) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOTALREADY ON INVENTORY IN A CUPA PROGRAM =$24.001 FACILITY <br />$ <br />Removal or Permitted Closure in Ptace <br />TANK ID I (s) : I CLOSURE FEE =$294 /TANK # TANKS X 5294 e $ <br />I TANK Iii # (s) : I TEMPORARY CLOSURE FEE = $294 / FACILITY I $ I <br />REPAIR PLAN CHECK ' <br />TANK ID #F s <br />$ <br />TANK RETROFIT REPAIR FEE _ $294 !FACILITY use for ipr;mitq3,ju buckets, tarn sura , Host. <br />$ <br />PPING REPAIR FEE = $294 / FACILITY (use for ' ' under-dspenser contairunent. ecL) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE = $ 20 <br />$ <br />'CONSULTATION FEE = $ 90/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 981 HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 981 HOUR <br />Af t =on AD= QAQ=n nee TUG eon un M., <br />$ <br />► 22 _ R1. <br />S- d 2b69 T 91s602 ou I sjo-4oejjuo0 Al aI i T 3 d90 = T 0 20 06 unr <br />