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SAN XOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTME14T <br />304 East Webor Avenue, Vd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (Sojloor): (209) 4683433 Web: w w.dgov.ors/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />APPLICANT MAILING ADDRESS <br />L Vt <br />APPLICANT HONE 99 WITH AREA CGDE <br />FACILITY ADDRESS <br />SITE PHONE it WITH AREA CODE <br />CITY <br />STATE ZIP CODE # OP TANKS AT SITE <br />2004 <br />CA 9 t - <br />APPLICANT BILLING. NAME <br />APPLICANT CONTACT NAME <br />APPLICANT MAILING ADDRESS <br />L Vt <br />APPLICANT HONE 99 WITH AREA CGDE <br />CITY STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />2004 <br />(l <br />Closure In5tsllawn pair Retrofd <br />j f <br />ACTIVE FACILITY <br />TRANSFER FEE _ $ 20 <br />2000 2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$500 FEE INCLUDES FACILITY FEE * I TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />SAMPLING INSPECTION FEE _ $ 931 HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTYASSEwSSED <br />TANK SURCHARGE _ $151 TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUFA PROGRAM x$24.001 FACILITY <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = $ 931 HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />SAMPLING INSPECTION FEE _ $ 931 HOUR <br />A66 rmlior^ ac o.—..—.--4—nmaM.sra r.n aG .v...=....... ....vr.......—...®...oe—--'---'—''---__ <br />OFFICE USEONLY . <br />SERVICE REQUEST# I FACIUTY ID I ANK M T j7tR a CHECK 0 1 RECEVED BY I DATE RECEIVED <br />SR <br />EN 23 032 (REVISED 002MM <br />