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i 3 <br /> SAT[JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Sheet,Stockton,CA 95202-3029 <br /> Telephoner(209)468-3420 Fax.(209)468-3433 Web:www.sigov.orglehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> AT9.rr 1: UF02 N'1I Udkrsp, <br /> FACILITY ADDRESS SITE PHONE 0 WITH AREA CODE <br /> 34S N saw T ,^ Sb. o r(, cnZ -2400 <br /> CITY STATE I ZIP CODE I f OF TANKS AT SITE <br /> -S CA <br /> APPLICANT WILLING NAME APPLICANT CONTACT NAME <br /> Slo•Ecc. Ascoli&dz*e C"W <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 11'x-4 0. 70-+ 165- 14-40 <br /> CRY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> " I* Closure InstaNation epair trout 'TgD <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> &SW FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY AS5E35ED $ <br /> TANK SURCHARGE-1151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM X49.001 FACILITY <br /> PERMANENTCLOSURE <br /> or Peffiddod Cbsure In Placa <br /> TANK IA>I(o): CLOSURE FEE■ 451TAIdK #TANKS X$345= $ —' <br /> TEMPORARY CLOSURE <br /> Plan Review and I <br /> TAW[DO(s): TEMPORARY CLOSURE FEE_$3451 FACILITY is <br /> INSTALLATION PLAN CHECK <br /> Chad-and Conskuckn Ins <br /> TANK ID 4(s): PLAN CHECK FEE $920/FACILITY $"~ <br /> REPAIR PLAN CHECK <br /> TANK ID f(s) <br /> TANK RETROFIT REPAIR FEE =$345!FACILITY (use for monitwing equipment,cold starts.EVR upgrades, -- <br /> ill buckato6 sumps,misc. <br /> PIPING REPAIR FEE a 1 FACILITY use for piping,undw-dioeMoor containment,act. $345— <br /> WSCELLANEOUS <br /> $ <br /> TRANSFER FEE 420 <br /> CONSULTATION FEE 115!HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE a $1151 HOUR <br /> SAMPLING INSPECTION FEE 11151 HOUR <br /> ALLFEES ARE HASEG ON THE$11S HOURLY RATE.TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERWCE RE ESTN FACILITY ID AMOUNT RECEiVBD I CHECK A I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 932(REWSED 07[01!19) <br />