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05!27/2005 :5: 2E 20946fw3 FIFTH FLpDIR • PAGE 03 <br /> SAN JOAQUIN COLWW <br /> ENVIRONMENTAL HEALTE DEPARTNJEN r <br /> 304 East Weber Avenue,3rd Floor,Stockton,04,9S202-27709 <br /> Telephone,(209)4683420 Fax(50floor):(209)463-3433 Web:www.sieov.wWohd <br /> fKaLITY NAME FACILITY CONTACT NAME <br /> /`tib <br /> _ 'S :,i <br /> !AGILITY ADDR STITS PHONE 9 WITH AREA 00DE <br /> GTN STATE LP CODE •OFT AT <br /> n <br /> S_Sr �C.-i..� ICA cP.l��� +.i'% F:.{r �2 tc�: .-�'Mr'_X <br /> APPLICANT EILLiNG NAhTE APPLICANT CONTACT NAME <br /> LICANT MAILING ADDRESS APPLICANT PNONE s WITH ARFA LADE ---1 <br /> � Po 6�x. 7551 zs5��fsa- <br /> GITY +I�I STATIE ZIP CODE <br /> COODtE CIRCLE WORK TO Be CONE � CONTRACTOR ICC C <br /> "\T� I zgI ;Iowm msulleeon R.epa ReVoflr <br /> ACTIVE FACILITY — . <br /> 2000 1 2001 2002 2003 2004 200b <br /> $900 FEE INCLUDES FACILITY FEE+1 TANK I I i <br /> $125 PER TANK AFTER FIRST TANK <br /> ' r $ <br /> TANK PENALTY ASSESSED ' _ IS <br /> TANK SURCHARGE=5151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA COPA PROOPAM-524.901 FACILTTY $ <br /> i <br /> PERMANENT CLOSURE <br /> {Rame'Vai or Farmkted Crosum In Place <br /> TANK ID 3 s CLOSURE FEE=5275/TANK 9 TAN X$27 = $ <br /> TSM C <br /> Plan P,edew and InspeL9ona) <br /> TANK ID 0(s)i TEMPORARY CLOSURE FE==S2791 FACILITY $ <br /> I <br /> INSTALIATION PLAN CHECK <br /> Plan cne:k and comItuefion 1 n®) <br /> TAN0KIDS(5); PLAN CHECK FEE_$7441 FACILITY <br /> REPAIR PLAN CHECK <br /> TANKID3 <br /> TANK RETROFIT REPAIR FEE =$279!FACILFTY uae fbrrrpnitarkig equIPMOnt.e091 L>uCcels.tanK sumps.mise) '. $ <br /> PIPING REPAIR FEE =$2791 FAOL1TY hese for ping,under-diwenNv containTten4 cut. $ <br /> MISCELLANEOUS -- <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $031 HOUR $ I <br /> U14AUTHORIZED RELEASE EVALUATION FEE = S 931 HOUR $ <br /> SAPoIPLIN'IrJSFECT!OIJ F E = S 83!HOER $ <br /> ALL FEES ARE BASED ON THE Wa HOURLY FN TINE THAT IMCEEDS FEFS PAID W"NE BILLED TO ..ANT. <br /> OFFICE USE ONLY <br /> SMRVICEREO:IESTA _ACILITYlO_ I AMOUNTREcrwED CHECKt I RECEIVED W. DATE RECEIVED <br /> SR I I <br /> EM 23042(FMI D0:@ 5) <br />