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SAN TbAQUIN COUNTY <br /> ENVIRONMENTAJ HEALTH DEPARTMENT . <br /> 304 East Webor A'Veme,3''4 Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Pax(rfioor):(209)4683433 Web:w w.sisov.ose/obd_ <br /> FACILITY NAME FACILITY CONTACT NAME <br /> CkEuRoi <br /> FACILITY ADDRESS SITE PHONE*WITH AREA CODE <br /> (Qaq7 <br /> CI'T'Y STATE ZIP CODE #CF TANKS AT SITE <br /> GA .- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> S <br /> APPLICANT.MAILING ADDRESS APPLICANT PH NE#WITH AREA CODE <br /> 0 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation R ai Retrofit T' <br /> ACTIVE FACILITY <br /> 2000 2001 2002 200$ 2004 2.005 <br /> $500 FEE INCLUDES FACILITY FEE*1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE m$15 1 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUFA PROGRAM®$24.001 FACILITY <br /> PERMANENT CLOSURE <br /> Ramoval or Permitted Closure in Place <br /> TANK ID (p): CLOSURE FEE w$279.1 TANK #TANKS X$279 e $ <br /> TEMPORARY CLOSURE <br /> Alan Review and fns cUons <br /> $ <br /> TANK ID#(s): ITEMPORARY CLOSURE FEE=$279!FACILITY <br /> INSTALLATION PLAN CHECK <br /> Pian Check and Construction inspections) <br /> TANK ID 0-(p) PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK tD#(s),: <br /> TANK RETROFIT REPAIR <br /> .FEE m$2791 FACILITY uss for monitoringa ui ment,s III buckets,tank sumps,mise.) <br /> .•� PIPING REPAIR FEE 2791 FACILITY two for piping,and®r-dis onset containment ect. 7 '—"" <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 <br /> $ <br /> CONSULTATION FEE _ $93)HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE '. _ $93/HOUR <br /> SAMPLING INSPECTION FIE m $931HOUR <br /> ALL FEES ARE BASED ON THE$83 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE RIILND TO APPLICANT. <br /> OFFICE tISEONLY <br /> SERVICE RECUEBT# FACILITY ID AMOUNT RECt D CH-ECKA 1 RECEIVER BY DATE RECEIVED <br /> SR <br /> EN 23 032(REVISED OZ-Zbt ) <br />