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08/21/2006 15:54 4640138 ENVIRONMENTAL HEALTH PAGE 01 <br /> SAN JOAQVIN COUN'T'Y <br /> ENVOtONMENTAL HEALTH DEPARTMENT <br /> 304 FAm Webcx Avenue.3'Hoar,Stoddon,CA 95202-2708 <br /> TdWhane:(209)468-3420 Par(S'"f r):(209)468-3433 Web_www.s' v.a r <br /> ACILITY NAME FACILITY CONTACT E <br /> FACIL ADDRESS AREA CODE <br /> �u #OF TANKS AT SITE <br /> CRY <br /> sT CODE <br /> CA <br /> APPLICANT BILLING NAME APPLICAN TACT NAME <br /> a - P <br /> LK:ANT MASLtl�16 ADDRESS PHONE f WICODE <br /> TH AR <br /> Tl'4 i JJ CvYh , <br /> CITY TE ZIP CODE CLE TO BE DONE CONTRACTOR ICC 8 <br /> Cbsm k obtlon Repair Reb-M <br /> ,l <br /> ACTWE <br /> FACLITY <br /> 2001 2002 2003 2004 2005 200fi <br /> $500 FEE INCLUDES FACILITY FEE+1 TAM( 5 <br /> ;125 PER TANK AFTER FIRST TANK <br /> LANK PENALTY ASSESSED 5 <br /> TANK SURCHARG9=S15/TANK $ <br /> STATE SI tCNARGE FOR FACILITES NOT ALREADY ON V4VENTORY IN A COPA PROGRAM eW4Ao1 FACILITY <br /> p CLOSURE <br /> Ramer or PsrmiHed ClosvrC i►Place �, <br /> TANK 10* s <br /> CLOSURE FEES 52851 TANK TANKS X 1285= <br /> CLOSURE <br /> (plan RwAaw and $ <br /> FACILITY <br /> TANK ID 0(s) TEMPORARY CLOSURE FEE=2285/ <br /> IN ALLATK3N PLAN CNECK <br /> Plan Ct�dc and ConsbMx:Eon! <br /> TANK ID 8(sI PLAN CHECK FEE=5760!FACILITY <br /> R / PLAN C1lECK <br /> TANK ID ff S : <br /> TANK RETROFIT REPAIR PEE =52851 FACILITY use for <br /> sw <br /> txick*tc tw* 5 <br /> P►PING REPAIR FEE -S2851 <br /> use for under �.ed <br /> M S 5 <br /> TRANSFER FEE = 5 5 <br /> CONSULTATION FEE = S NOUR b <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 951 HOUR 5 <br /> SAMPLING INSPECTION FEE = S 95t HOUR Plug w�eE To <br /> ALL FEES ARE 01i TIME ff5 pOURLY RAZE iM T f*lF.S <br /> OFFICE USE ONLY Auoew READ a+ECK it 8Y onTE REGEIV� <br /> REQ!)EST E ALILIIY D <br /> SR <br /> EN 4s o3z 1REvmo Orr^") <br />