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SAN JgAQUIN COUNTY <br />1 ENVIRONMENTAL HEALTH DEPARTMENT F <br />i, 600 East Main StrFrreet, Seackton, CA 95202-3029 <br />TelepJrorte: (209) 46$-3420z, (2p) 468$-J33 Webs wva,s' ov,or /ehd r ; <br />FACILITY NAME <br />I FACILITY CONTACT NAME <br />FACILITY AA DRESS <br />S TE PHONE # WITH AREA CODE <br />CITY I I . -- <br />} STATS <br />f i v !lJll i • CA ZrP c�[JS # OF TAN -S- <br />AT ' <br />5 <br />APPLICANT BILLING NAME ' I <br />APPLICANT CONTACi.NAME.... <br />APPLICANT MAtL1NGA-)-6R ESS <br />APPLICANT PHONE # WITH ARlvq C:pDI <br />STATE ZIP CODE _ <br />_ CIRCLE, .DONE <br />........ --CONT <br />ACTIVE FACILITY RACTOR IGC <br />TY <br />Closure Installation Re air Relront <br />i <br />$504 FEE 1NCLUbE"a FACILITY FEE + i TANK (2068-2007) 2006 2007 20Q8 2000 2QiQ zQi I <br />$560 PEE INCLUDES FACILITY FEE + 7 TANK {2008-2071) i <br />$426 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARrtip = Qqr, 1 -rend. <br />.nLMr %UY UN INVENTORY IN A CUPA PROGRAM=$49.00J FAC1117Y <br />PERMANENT CLOSURE <br />Removaf or Permitted Cfo$ure In Place <br />TANK ID # {s7 ; <br />TEMPORARY CLOSURE CL03URF FEE - $375 /TANK # TANKS X 4375 = <br />Plan Revlew and Ins eciicns <br />TEMPORARY CLOSURE FEE a $375 F FACILITY $ <br />INSTALLATION PLAN CHECK <br />Plan Check and Cons'traCllonlns actions <br />TANK ID # (,q): <br />PLAN CHECK FEE _ $7,000 I FACILITY <br />REPAIR PLAN <br />TANK 1D # (s) <br />'TANK RETROFIT REPAIR FEE75.1 F�1C1-.-17_-Y (use lKo_rmo=nitori-n—g a_ut me—n—t, _oo_ld.st <br />arts, EVR u ramist, des-, <br />- <br />PIPING REPAIR EE $375 <br />/FACILITY <br />use 'for' 11n ,under dis ensur�conk <br />MISCELLANEOUSalnment,act. <br />TRANSFER FEE Z$ <br />�t�JN�ULTATION FEE _ <br />$ 125/ HOUR.. <br />UNAUTHORIZED rRELEAEE EVALUATION PEE _ $ 126 / HOUR <br />SAMPLING iNS.PEXTION FEE <br />" 125/•HOUR- <br />ALL-FEES AR@ -BASE <br />d ON� 12! HOURLY-HATE:"-TIME"FHA-T EXCEEDg `ESgpAIC WILL 9E BILLED p� pLICAN- L <br />TOTA4 AMOUNT DUE <br />OFFICE USE ONLY. _ .... <br />SERVICE REL7UEST#- FACIL-ITY'1i7 <br />CHECK #_. _.,. <br />REC i IVSD BY LATE ReCEIVED <br />EH 23 032 (REVISED 0011111 by KF) <br />