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17r2008 08: 24 2640136' ENVIRONMENT toHEALTH PAGE 06/07 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL}iEAI,TH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fat:(209)468-3433 Web:~�rwy.siPov�oC�e s}� <br /> FACILITY NAME FACILMY CONTACT NAME <br /> FACILITY.AL)DRESS SITE PHONE#NTH AREA 0 E <br /> '568 LAc. <br /> CITY I STATE I ZIP CODE 0 OF TANKS AT SITE <br /> CA � <br /> APPLICANT NAME APPLICANT CONTACT NAME <br /> ' Qc ) <br /> APPLICANT MAILING ADDRESS APPLICANT PHON it WITH AREA CORF <br /> CITY STATE 21P CODE CIRCLE WORK T4 ONE CONTRACTOR ICC <br /> � - Closure Installs' Repair Retrofit <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2008 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+t TANK(2002-2007) <br /> Fk550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK$URCHARGE w$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM-$214.001 FACILITY <br /> P€RhIANEN7 CLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID# s CLOSURE FEE c$2941 YANK #TANt$X$294= <br /> TEMPORARY CL03URE <br /> Plan Revi2W and Ins eetions <br /> TANK 10#(s): TEMPORARY CLOSURE FEJT-$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Cvneirucllan Ins aiivns <br /> l $ <br /> I TANK ID#(s): PLAN CHECK FEE-$7841 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$2941 FACILITY (use for manitoring equipment,cold starts,EVR upgrades, <br /> spill buckets sum2l,mise. <br /> PIPING REPAIR FEE _$294 1 FACILITY use for 2121Q9,under-dispensm contalnmeni.act. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $2C <br /> CONSULTATION FEE = $9111 HOUR <br /> UNALTHORfZl^D RELEASE EVALUATION FEE = $981 HOUR <br /> SAMPLING INSPECTION FEE = $981 HOUR <br /> ALL MILES ARE BASER ON THE$99 HOURLY RATE. TIME THATEXCXEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST A 1 FACILITY IDAMOUNT RECEWW/EA CHECK# R4CEIYED aY DATE RECEIVED <br /> 5R I I -j <br /> EFS 23 032(REVISED 12/31f071 <br />