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' 0 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMO <br />304 East Weber Avenue, 3`a Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5* floor): (209) 468-3433 Web: www.sjgov.or /g ehd <br />FACILITY NAME FACILITY CONTACT NAME <br />Go I IL T -o P '- If ZS'— I m E lL A4L v E. c o 'r <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />f.5-60 W - W141 84 <br />CITY STATE ZIP CODE # OF TANK <br />2tPotit CA 9536 b 3 <br />G(/A c. r o P( <br />4PPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />P. o, goX /®is 9lb 3�3- tcsi- <br />:;ITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONT' <br />l/" . !: C A S-` Q t Closure Installation epair Retrofit <br />ACTIVE FACILITY <br />2001 2002 2003 2004 2005 2006 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />(Removal or Permitted Closure in Place) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />= %285 / TANK # TANKS X $285 = <br />CLOSURE FEE = $285 / FACILITY <br />PLAN CHECK FEE = $760 / FACILITY <br />ICC # <br />TANK RETROFIT REPAIR FEE = $285 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) n <br />PIPING REPAIR FEE = $285 / FACILITY (use for piping, under -dispenser containment, ect.) <br />