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08/21/2006 15:54 4640138 ENVIRONMENTAL HEALTH PAGE 01 <br /> SAN JOAQUIN COUNT V <br /> ENVIRONMENTAL HEALTH DEPAR <br /> AM <br /> 304 East Webcr Avenue,3"Floor,Stockton,CA 95202-2708 <br /> Tctcpkone:(209)468-3420 Fax(1"'floor):(209)468-3433 Web:wwwsieov.urg/chd <br /> FACILITY NAME FACRITY CONTACT NAME <br /> Lvyl tl S � ! N-4-\C(- <br /> FACILITY ADDRESS k SITE PHONE k WITII AREA CODE <br /> 1 yup <br /> CRY STATE ZIP CODE f OF TANKS AT SITE <br /> CA <br /> APPLICANT BWNG NAME APPLICANT CONTACT NMtE <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE a WITH AREA CODE <br /> Lc w�A <br /> CITY STATE ZIP—CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC k <br /> %)-FA„\C� ( r pt Cbstu® Insleaatlon Rapalf <br /> I �eTroi <br /> AC TVEE FAG YILRY <br /> 2001 2002 2003 2004 2005 2006 <br /> 5500 FEE INCLUDES FACILITY FEE t 1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=515/TAW $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=524.001 FACILITY <br /> P RMANENT CLOSURE <br /> Removal or Permitted Cbsure in Place $ <br /> TANK ID k s CLOSURE FEE=52851 TANK k TANKS X$285 <br /> TEMPORARY CLOSURE <br /> Plan Revlaw and b cd $ <br /> TANK ID k(si:- YEMPORARY CLOSURE FEE=$285/FACILITY <br /> ET <br /> LLATION PLAN CHECK <br /> Chock and Construction M d'gns $ <br /> ID k)s): PLAN CHECK FEE_$7601 FACILITY <br /> R PAIR PIAN CHECK <br /> TANK lDk s $✓ 77 <br /> TANK RETROFR REPAIR FEE _$2851 FACILITY use for mwitortn I sill bockats,tank sum •mist: I <br /> PIPING REPAIR FEE =$285/FACILITY <br /> use for plong.under m Cantainment ori. <br /> MI CELLA14EOUS $ <br /> TRANSFER FEE = S 20 $ <br /> CONSULTATION FEE = S 951 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 95/FK)UR $ <br /> SAMPLING INSPECTION FEE S 951 HOUR <br /> ALL TEES ARE BASED dJ TRE ffs HDDRLY RATE. TIME THAT IXCEEDS FEES PNO WILL BE enLEo TD APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REGl1E5ra FAGIm ID <br /> AMWN,lRECEIVED WECKF <br /> RECEIVED eY DATE RECEIVED <br /> SR <br /> 15—123 M(REVISED OT124008) <br />