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SAN JOAQUIN COUNTY <br />` ENVIRONMENTAL HEALTH DEPARTM .' <br />304 East Weber Avenue, 3'd Floor, Stockton, CA 95202-2708 <br />Telephone. (209) 468-3420 Fax (5hfloor): (209) 468-3433 Web: www.sjaov.org/6hd <br />FACILITY NAME FACILITY CONTACT NAME <br />t.'V oa tJeCC- 11 fn, � <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />CITY STATE ZiP CODE <br />1r � � # OF TANKS AT <br />CA a r Z <br />fTC <br />'PLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA C <br />3 0 3 2- e r f I> b t2 cyi a.c C� (� 6 <br />TY STATE ZIP CODE CIRCLE WORK TO BE DONE <br />Closure Installation Reoair�fl� <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK 2002 2003 200 4 2005 2006 2007 <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 <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place) <br />TANK ID # s <br />TEMPORARY CLOSURE -:::CLOSURE FEE = $285 / TANK <br />Plan Review and Inspections) <br />TANK ID # (s) : TEMPORARY CLOSURE FEF = T9R! <br />(Plan Check and <br />TANK ID # (s) : <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $285 / FACILITY <br />PIPING REPAIR FEE = $285 / FACILITY <br />for <br />FACILITY <br /># TANKS X $285 = <br />NO <br />PLAN CHECK FEE = $760 / FACILITY <br />OFFICE USE ONLY <br />