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.SAN JOAQUIN COUNTY <br />ENv1RONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3n1 Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5°M JJeor): (209) 468-3433 Web: www.sieov.ore/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />i�►i <br />N I 6eA( L <br />ivi G, NeGc <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />�j'fi) WArerLov Rd <br />2A i3 - Z Sc� <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />+dtk CA <br />1 CA <br />APPLICANT BILLING NAME <br />.... �........ __._..._.----.--- <br />le 6e er fC� <br />RN 1rJ 1 <br />APPLICANyT MAILIwe ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />1 VvQ. l©0 - <br />2,P50 <br />. <br />CITYSTAATE ZIP CODE <br />'KTuuruuN�j CONTRACTOR ICC # <br />e;+o ro" <br />1 CA <br />�pqzlClosure <br />Installation Repeir Ret n <br />J 2 <br />ACTIVE FACILITY <br />TANK ID # s <br />CLOSURE FEE _ $2791 TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />SAMPLING INSPECTION FEE = $ 931 HOUR <br />n eoo� ireur <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$151 TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.001 FACILITY <br />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s <br />CLOSURE FEE _ $2791 TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />MISCELLANEOUS <br />DATE RECEIVED <br />SR <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 931 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 931 HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 931 HOUR <br />n eoo� ireur <br />ALL FEES ARE BASED ON TAE 893 HOURLY n I c- TiMcI ! a ....cw r..... ..��� <br />VrrWC UOC vnu <br />SERVICE REQUEST If FACILITY to AMOUNT RECEIVED CHECK# RECEIVED BY <br />DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 02127105) <br />