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R g���J <br /> SAN JOA COUNTY <br /> S <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3'd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)458-3420 Fax(S'h floor):(209)468-3433 Web:vaww_�ovov 8/ghd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> V 3 7 N. GJ,'1x-,7 -),o `?YoZ - a ? Y <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Ss�cc k�av, CA 96'a OS- I--)- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> p <br /> wm %dam ! reE r' .5-"On 7—exra * C ..c'�k <br /> APPLICANT AMAJW ADDRESS APPLICANT PHONE#WWTH AREA CODE <br /> P. o. 49o,Y 6'3 9R s6/ 36'3- a you <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> cc 93R?Pis' Closure Installation Retrofit S.ZSd V9��uT <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $600 FEE INCLUDES FACILITY FEE+4 TANK <br /> $126 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM X24.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Plac® <br /> TANK 10#(s); CLOSURE FEE-$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> Ian Review and kng2A2nsj <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2791 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction In cdions <br /> TANK ID#(s); PIAN CHECK FEE_$744/FACILITY <br /> REPAIR pri7w CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,misc.) <br /> PIPING REPAIR FEE =$279/FACILITY use for piping,under-dispenser containment,wL $ <br /> MHWXdAANEOUS <br /> TRANSFER FEE = $20 $ <br /> CONSULTATION FEE $93/HOUR $ <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ALL FEES ARE BASED ON THE 03 HWALY RATE. TIME THAT EXCEEDS FEE$PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILrCY is AMO=RECISIEO CHECK# I RECEIVED SY I DATE REG <br /> SR <br /> EH"on ;No <br />