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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3'd Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fox(5`"floor):(209)468-3433 Web:wwws' ov.or /F ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> S�/"e�// C TaAh <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> f2 y F yose .n. l�e A�� zQy P" <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> 6./?'lam ec CA ?:5-F 3 <br /> 6 <br /> APPLICANT BILLING NAME APPLICANT CONTACT <br /> /NAME <br /> APPLICANT MAILING ADORES APPLICANT PHONE#WITH AREA CODE <br /> '�" %00 Ste^ Ze4n a "/ 3q�3 - 7 '/d0 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 144 nc eC C'.r-1 9Y13 d Closure Installation Repair Retrofit �p�7gy crC�_ 2 <br /> ACTIVE FACILITY <br /> 2006 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2002 2003 1 2004 2005 <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM x$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> YANKID# s CLOSURE FEE=52851 TANK #TANKS X$285= <br /> TEMPORARY CLOSURE <br /> Pian Review and Ins Cllons <br /> TANK ID#(s): TEMPORARY CLOSURE PEE_$285/FACILITY <br /> INSYALLATION PLAN CHECK <br /> Plan Check and Construdon Inspection) <br /> TANK ID#(s); PLAN CHECK FEE_$760/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK 00s T-1 — e cF 7 -- <br /> TANK RETROFIT REPAIR FEE _$285/FACILITY use for mondorin a ul ment,spill buckets,tank aum s,misc.) $��$ <br /> PIPING REPAIR FEE 7$285/FACILITY use for piping,under4speft8ar containment.ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 <br /> CONSULTATION FEE _ $951 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 951 HOUR <br /> SAMPLING INSPECTION FEE _ $- A—HO <br /> 5/HOUR <br /> ALL FEES ARE BASED ON THE$95 HOURLY RAT& 110.7E THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REOUEST# FACILITY ID I AMOUNT RECEIVED T CHECK# 1 RECEIV BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 01129/071 <br /> L01£0 39Vd _dIH >ICf1H0 EZS££6ET99 4£:TT 800Z/1Z/b0 <br />