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07/17/2008 08:24 2 40138 ENVI HEALTH PAGE 06/07 ie SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468.3420 F= (209) 468-3433 Web: gDv.oi-�ehd FACILITY NAME APPLICANT CONT/ACCTT NAME FACIOW CONTACT NAM Lw 11" FACILITY ADDRESS APPLICANT MAILING ADDRESS SrW PHONE # VATH AREA CODE 12, 2008 -- CITY IL I STATE ZIP CODE #a: TANKS AT SITE �o CA SAMPLING INSPECTION FEE - $ 98/ HOUR APPLICANT NAME APPLICANT CONT/ACCTT NAME p APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA COPE ¢ L.'Q rl*z 6�c 2008 C TY STATE CIRCLE WORK E DONE NTRACTOR 10 # S"'?.,,0 t Closure Instana air ®trout 2 t{ ACTIVE FACILITY TANK ID # (s) : 2003 2004 2006 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) PIPING REPAIR FEE _ $294 t FACILITY use for WDIng. under-0iiipansw crontalnment. Oct.)$ UNAUTHORIZED RELEASE EVALUATION F $ 981 HgVR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) SAMPLING INSPECTION FEE - $ 98/ HOUR $ $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM -$2.1.001 FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ $ TANK RETROFIT REPAIR FEE = $294 / FACILITY (use for monitodng equipment, cold starts, EVR uP9mdes, s 11 4 dcets sum miss CONSULTATION FEE = S 981 HOUR PIPING REPAIR FEE _ $294 t FACILITY use for WDIng. under-0iiipansw crontalnment. Oct.)$ UNAUTHORIZED RELEASE EVALUATION F $ 981 HgVR MISCELLANEOUS $ TRANSFER FEE = $ 20 $ CONSULTATION FEE = S 981 HOUR $ UNAUTHORIZED RELEASE EVALUATION F $ 981 HgVR $ SAMPLING INSPECTION FEE - $ 98/ HOUR Ab1. raw M%r. OAAOV Vn I KC Etl6 FIVVK61 MA I6. 1 WIC IMA 1 TW APPI, L;AA I. OFFICE USE ONLY SERVICE REQUEST A FACILITY ! NT RECEIVED CHECK 0 R CEIVED BY A RECEIVED SR EH 23 032 (R"3ED 12/31/07)