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. SAN JOAQUTN COUNTY • <br /> ENViRONMENTALHEALTHDEPARTMENT _ <br /> 304 East Weber Avenue,3"Floor,Stockton,CA 95202.2708 r <br /> 71e[egnonx:(209)468-3420 Fac Od floor)i(209)468-3433 Web:wwv sinov. and <br /> i FACiUT'T NAFhE FACILITY CONTACT NAME <br /> 1 FACII-RTY ADDR S$ SITE PHONE#WITH AREA CODE <br /> 7-07967- ( b Z2- <br /> -a—Ty STATE ZIP CODE I �P OF TANKS AT SITE <br /> ?x'P'-1C.:,N'd 6iLLING NA ME APPLICANT CONTACT NAME nm•._�W <br /> APPI fd-MT MAILINC ADDRESS APPLICANT PHONES WITH AREA CODE <br /> GIT`t STATE ZIP CODE CIRCLE WORK TO BE DONE 5554fl P:CT5D ICC L" <br /> losure Instanation Repair' Retrofit T <br /> A(TFVE FACILITY <br /> 2000 2001 2002 2003 2004 <br /> $$$125 FE 2005 <br /> ZGO F--INGLUCES=ACILFiY FEE+t TANK <br /> TANK A•=TER FIRST TANK —I — <br /> TANK PENALTY ASSESSED jj' $ <br /> TANK SURCHAP,CE=5151 TANK <br /> I STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=;24.001 FAGILITf <br /> FFF-mm H=NTCLOSURE . <br /> (Removal a. Pa=it ed Closure in PfaCe q <br /> IANK.IDM & ; 050 -760-7 CLOSURE FEE=$2791 TANK #TANKS 7C$213= ! <br /> TEMPORARY CLOSURE -- <br /> v ;Plzn Rsra�r+and Ito ecdonsl <br /> TAAIKID-(s): TEMPORARYCLOSUREFEE=5279/FACiUTY•• $ <br /> i' NST Ai.LITN 11 FLAN CHECK <br /> 'Plan Check and Loran don Ina aeuons <br /> ' TANK 17;1 t -v <br /> i ( ) PLAN CHECK FEE=$7441 FACILI I <br /> REFAIiR FLAt9 CHECK <br /> TA,^1K IDS{£1: I ' <br /> TANK R-Tl RQMT REPAIR FEE =$2791 FACILITY use for monitonn equipment,s Ili buckels,rank gum c,mist. i. <br /> PIPINGRF_PoJF.F='c =$27g/FACILITY (use far Piping under-dispensercontamment act) <br /> h41SCE'_P�Nt3OVS ' <br /> I .-r ANSFER FEE = $'29 <br /> CONSU4TA1ION FEE = 5931 HOUR <br /> UNAUTHORItEO RELEASE EVALUATION FEE_ = 5 931 HOUR' I <br /> ILSAAMMPUNG INSPECiiON FEE = 5 931 HOUR <br /> hLL F.eS AR BASED ON TI1E 3a3 HOVRLY RATE TIME YHAT EXCEEDS FEES PAID WILL BE BELLED TO APPLICANT."� <br /> OFFICE USE ON--f <br /> FEQURS7-- I FACIUTY ID ANOUNTRECEIY£D CHECKS RzGavE➢E'Y GaTG RccciL'Evl <br /> SdS <br /> Eli 210 2 IR-EYi6ED OZM:05) . <br />