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ETNIROM£MTAL HEALTH PAGE 01 <br /> 8 <br /> 08121!2006 15:54 464013 • _ <br /> SAN JoAQUaICOUNTY <br /> ENVIRONMRffAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue.3d FIM,Stoatm CA 95202-2708 <br /> rdWhone:(209)468-3420 Par(r,`flvvo:(209)468-3433 Web:ry nw.s v. <br /> F CONTACT NAME <br /> AC ITY NAME L <br /> c n <br /> SITE PF10NE f 1MIM AREA <br /> FACILITY ADDRESS <br /> p 1 LL.I PCODE 0 f OF TANKS AT STYE <br /> STATE <br /> cfrY <br /> APPLK: CONTAll <br /> CT NAME <br /> APPLICANTOLLING NAME <br /> "' APplk PFIONE iMrtTH AREA CODE <br /> APP K: T NAIL �G ADDRESS (9�-! /_ --2,> eICC� <br /> � 1 ;2,/e6 • <br /> STATE / ZIP CODE CIRCLE WORK TO fIE DOME <br /> DONE <br /> CITY 7b��J Cb.. wofto n Refit <br /> ACTM FAC6JTY 2004 2005 2006 <br /> 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE t t TAMC $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> i <br /> TANK SURCHARGE=S15/TAMC ROGRAM c$24.ON FACIIJTY <br /> STATE SURCNARGE FOR FACILITIES NOT ALREADY ON p4\1EfRORY IN A CVPA P <br /> PERA�Ea PwmdEetl CaD iw <br /> ;n Place <br /> a,OSIIRE Ff#=SZ�1 TAMC f TANKS X Y155` <br /> TANK IO f 5 <br /> TEMPORARY CLOSURE i <br /> (Plan RBvlaw and <br /> TEt,Ippgp,Rv(xpSURE FEE=52851 FACILITY <br /> TANK ID f(s): <br /> INS ALLATM PLAN CHECK i <br /> Plan Check and CO"Im lbn 1 PLAN CHECK FEE.5760/FACILITY <br /> TANK 1011(3): <br /> REPAIR PLAN CHECK <br /> TANK ID f 5 : '0 bu0kats,lade sum ^ i <br /> TANK RETROFIT REPAIR FEE =S285I FACIt-ITY use m - <br /> PIPING REPAIR FEE =$2851 FACILITY <br /> use for <br /> i <br /> N CELLANEOus <br /> RANSr"ER FEE _ s 20 — <br /> CONSULTATION FEE = S 95/HOUR <br /> - $951 HOUR $ <br /> UNAUTMOR <br /> O RELEASE EVALUATION FEE — <br /> FEES <br /> ION FEE = $95l HOUR T1Dt7 pcCEEDs FEES PAD 1aL.l BE P <br /> TO AppL}CANT" <br /> SA AARE ECTd TRE SK RDURLY RAYS TERE <br /> All RE ,.r=•' <br /> OFFICE USE ONLY AMdONr RECEIYEn <br /> CHECKf COYED DAi1:REfEi4Cl1 <br /> REBY <br /> _._ <br /> SERVICE REDUESF a AGLRYD <br /> EM 671211061ER 23 OU IREYISED <br />