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e4e z=;,355517888 Line 1 6:14 09-09-2013 6112 <br />SAN JOA.QUIN COUNTY <br />ENVIRONMENTAL HEALTH bEPARTMFNT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />--- .__-_- _- _ - —. --- . ----. _ _ --- ---- ---Te%phone: (209y469 3420rFaxc (204) 468-3433 Web vrwws' v.or8/ehd <br />FACILITY NAME FACILITY CONTACT NAME <br />FACILITY ADDRESS SITE PHONE S WITH AREA CODE <br />CITY STATE ZIP CODE # OF TANKS AT SITE <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />TANK iD# W: <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />F 0TANKSX$375= <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Closure installation Repair Retrofit <br />$ <br />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK iD# W: <br />CLOSURE FEE=$37517ANK <br />F 0TANKSX$375= <br />TEMPORARY CLOSURE <br />Plan Review and ins ectlons <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $3751 FACILITY <br />TANK RETROFIT REPAIR FEE = $3751 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, suma, misc. <br />PIPING REPAIR FEE _ $ 1751 FACILITYuse for i in ,under -dispenser containment, ect $ <br />MISCELLANEOUS <br />TRANSFER FEE = $ 25 <br />$ <br />CONSULTATION FEE = $125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $1251 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $1251 HOUR <br />$ <br />--- . --- . -.--...---.-.....- ....�............. ....... .............w.........r r swe+ a..ir wu a.cn.cu ov nrrs.wnea �. <br />TOTAL: AMOUNT DUE <br />