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• 11/10/2005 08:24 209468W EHD • SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 304 East Weber Avenue, Yd Floor, Stockton, CA 95202-2708 Telephone: (209) 468-3420 ,Fax (5" fPoer): (209) 468-3433 Web: www_sjgov.or /g ehd PAGE 03 FACILITY NAME FACILITY CONTACT NAME N arke tick �7"e cv� FACILITY ADDRESS SITE PHONE #WITH AREA CODE 5o I TQcksor Ary e v97 I CITY I STATE F ZIP CODE I # OF TANKS AT SITE scalor� CA q,55 2- 2 - APPLICANT APPLICANT BILLING NAME APPLICANT CONTACT NAME CLOSURE FEE _ $2791 TANK 2000 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 282 5i7adroadAvove, 279 S 7- 939 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # CP�es 957 Closure Installation Repair Retrofit $— ACTIVE FACILITY j TANK ID # (s)! CLOSURE FEE _ $2791 TANK 2000 2001 2002 2003 2004 2045 $500 FEE INCLUDES FACILITY FEE + 1 TANK $ UNAUTHORIZEO RELEASE EVALUATION FEE = S 931 HOUR $ SAMPLING INSPECTION FEE _ $ 931 HOUR $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE = $151 TANK j STATE SURCHARGE FOR FACILITIES NOTALREADYON INVENTORY IN A CUPA PROGRAM =$24.00f FACILITY :• PERMANENT CLOSURE Removal or Permitted Closure in Place). TANK ID # (s)! CLOSURE FEE _ $2791 TANK I # TANKS X $279 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $2791 FACILITY REPAIR PLAN CHECK TANK ID# (s): TANK RETROFIT REPAIR FEE _ $2791 FACILITY use for monitoring equipment, 011 buckets, tank sumps, misc. I PIPING REPAIR FEE = $279 / FACILITY juse fpr piping, under -dispenser wntdinment, ect. MISCELLANEOUS $ TRANSFER FEE _ $ 2b I $ CONSULTATION FEE = 5 931 HOUR j $ UNAUTHORIZEO RELEASE EVALUATION FEE = S 931 HOUR $ SAMPLING INSPECTION FEE _ $ 931 HOUR 1 V AM.L.RoA111 . OFFICE USE ONLY SERVICE REQIJEST I FACILITY ID &MOUNT RECEIVED CHECK 8 RECEIVED BY DATE REC61VEp SR EH 23 032 [REVISED OV22f05)