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08/21/2006 15:54 4640138 ENVIRONrENTAL HEALTH PAGE 01 <br /> • SAN JOAQUIN COUNTY 0 • <br /> &WM0NMENIAL HEALTH DEPARTMENT <br /> 304 End WeW Avenue.3'4 Floor,Stockton,CA 95202-2708 <br /> Tdgh,pnes(209)468-3420 .Paz(S"`floor):(209)468-3433 Webs www.s' ov. chd <br /> AGILITY NAME FACN.RM CONTACT NAME <br /> m LEO ` SITE—f I *YMtiN AREA CSE <br /> FACILITY ADDRESS /WW � <br /> T1r� <br /> CITY 1, 1 STATE CODE OF TANKS AT SIE <br /> CA <br /> NAME <br /> APPLICANT OLLING NAME AppLICANT CONTACT <br /> -APPLIl M LIN&AllPtICI1lE E Vr1111 �CODE <br /> C M <br /> �Ep C�O�m G CI r- TO AE DONE CONTRACTOR cxU �:J2 <br /> ICC!! <br /> 1 J�UPJ Instabtinn Retrofit <br /> FACILITY <br /> 2 <br /> 2001 2002 003 2005 2004 2006 <br /> SWO FEE INCLUDES FACILITY FEE•►1 TANK $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE==15!TANG $ <br /> STATE SURCHARGE FOR FAC1(,1TIES NOT AIJiFJWY ON INVENTORY IN A(SPA PROGRAM m$24.00(FACILITY <br /> p ANENT CLOSURE <br /> Removal or Pemiltd Cbmae in Pill <br /> $ <br /> CLOSURE FEE=52851 TANK fi TANKS K 5285 <br /> TANK ID fk'ill!: <br /> TR'MPORARY CLOSURE <br /> n Revkm and <br /> TANK ID#(s),. TEMPORARY CLOSURE FEE=1$286:/FA ILrrY <br /> I ALLATION PL AN CHECK $ <br /> Plan Chaci<and CansWcti°n I qns <br /> PLAN CHECK FIE=5760/FACILITY <br /> TANK ID#(s): <br /> R PAIR PLAN CHECK <br /> TANK ID fE(s): $J-5,c' <br /> TANK RETROFIT REPAIR FEE <br /> 1 FACILITY use for iU buckets,tank sun .misc. $ <br /> PIPING REPAIR FEE _ /FACILITY <br /> use for under cordaintnet►t,act <br /> M E $ <br /> TRANSFER FEE = S 20 $ <br /> CONSULTATION FFP = S 951 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 95 t HOUR $ <br /> SAMPLING INSPECTION FEE = 5 9W HOURTO App<lCANT- <br /> ALL FEES ARE OM TtiE Sts Ntil RATE. T9NE THAT©CCEEDS FL BE <br /> OFFICE USE ONLY At00UNT RECO tS1ECK A 6Y DATE lgEt:E1VED <br /> VICE REQUEST s FAa p <br /> SR <br /> Of 23 0321REVOED G7f2ilod) <br />