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08/21/2006 15:54 4640138 ENVIROKMENTAL. HEALTH PAGE 01 <br /> SAN JOAQM'CO>-114.1 1' <br /> 0 ENVIRONMENTAL HEALTH DEPAIt <br /> 304 East Webcr Avenw.3"Floor,Stockton,CA 95202-2708 <br /> Z'etcpkone.(209)468-3420 .Far(P fteer)r(2M)468-3433 Web:v►+ww.s ov.or chd <br /> FACILITY NAMIE FACLF Y CONTACT NAME <br /> 1 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA COPE <br /> '_ 1 1 -A Lot <br /> CITY STA ZIP #OF TANKS AT ITE <br /> CA 110 <br /> APPLICANTOLLINGRAME APPLK:ANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS AP PHONE!WITH AREA CODE <br /> c � <br /> bbl t�3� <br /> CITY STATE ZIP CODE CIRCLE WORK TO 5E DONE CONTRACTOR ICC @ <br /> Cimum InsWpation Repair Regroflt <br /> ACTIVE FACILITY <br /> 2001 2002 2003 2004 2aQ5 g006 <br /> S5W FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE suitCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=524.00/FACILITY <br /> IPMANENT CLOSURE <br /> Re or Permilled Closure«+ $ <br /> TANK ID#I(s): CLOSURE FEE=S /T #T X 5255= <br /> WM—FWAW CLOSURE <br /> n Review and cios <br /> $285/FACILITY <br /> INSTALLATION CHECK <br /> Plan Check and Construc8on I ans I $ <br /> TANK ID#(s): PLAN CHECK FEE=5760/FACILITY <br /> REPAIR PLAN{NECK <br /> TANK i[O# 5 <br /> Sb-*Ms.Isnk"m .tnlsC. <br /> YANK RETROFIT REPAIR FEE ^ 'FAGLfiY k�e ��+ -- <br /> PIPING REPAIRFEE _$285/FACILJTY koe for undue or rnntaMNIent Ca <br /> Mp$CELI-ww— S $ <br /> TRANSFER FEE ft.S $ <br /> CONSULTATION FEE 5 W HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 95./HOUR $ <br /> SAMPLINra INSPECTION FEE = S 09/HOUR <br /> ALL FEES ARE D ON THE s85 f"I Y RATE. TM TIiAT EXCEE0.5 FEES PAI1 WILL HE BttLED TO Apps!CANT. <br /> OFFICE USE ONLY <br /> S@ VICE IdEQUEST E FApLiTY a3 A150IINT <br /> RECEIVED$9 <br /> 5 RECE'V�@Y DAT€!DECEIVED <br /> SR <br /> EN 22 032OtEVISED 0728W) <br />