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08/21/2006 15:54 4640138 ENVIRONMENTAL HEALTH PAGE 01 <br /> SAN JOAQUIN COUNTY <br /> + ENVIRONMENTAL HEALTH I)EPARTMENT <br /> 3D4 East Webcr Avenue,34 Floor,Stocktm CA 95202-08 <br /> Telepkeae:(209)468-3420,F=(s"jbor):(209)468-3433 Web:www.s v. <br /> ACILfTY NAME FACILITY CONTACT E <br /> �n(901D �ls�S i1'llcha <br /> FACILITY ADDRESS SITE PHONE i AREA CODE <br /> STATE CODE •OF TANKS AT SITE <br /> Cm / <br /> ( A—) CA – /D <br /> APPLICANT BILLNG NAME AP ANT CONTACT <br /> (CANT NAIL APPLIC P!K)NE f WITH AR A CODE <br /> APPLX535 - <br /> CITY ZIP CODE CIRCLE WORK TO RE DONE CONTRA.CyT�OR ICC i <br /> ACTIVE FACILITY <br /> 2001 2002 2003 2004 2005 2006 <br /> S10 PFEE ER INCLTAW E.SFACI <br /> FlRStNK <br /> TANK FEE 1TAa <br /> S <br /> _TANK PENALTY ASSESSED 5 <br /> TANK SURCHARGE=$151 TAW $ <br /> STATE SURCTIARGE FOR FACILITIES NOT ALREADY ON IN4/ENTORY <br /> INA COPA PROGRAM-i24.Ob1 FACILRY <br /> P CLOStm <br /> itenoval or Pwmbed claalre n Pixe D <br /> CLOSURE FEE.57A5/TANK It TANKS X f2b5 <br /> TANK iD i 5 <br /> TEMPORARY CLOSURE <br /> n Re�lew aM <br /> TE WRY CLOSURE FEE=$285/FACILITYTANK ID 0(s): <br /> IN ALLATION PLAN CHECK s <br /> Plan Chndc and Construdon 1 <br /> PLAN CHECK FEE-two I FACIIaTY <br /> TANK ID i(sj <br /> R AIR PLAN CHECK <br /> TANK ID N s : <br /> dKkela Nnk <br /> TANK RETROFIT REPAIRFEE =$2851 FACILITY use for $ <br /> el <br /> PIPING REPAIR FEE =:2851 rACILfTY use for <br /> under <br /> N CELLANEOUS S <br /> TRANSFER FEE - S 20 $ <br /> CONSULTATION FEE = s 951 HdOUR E <br /> UN 17L-0 RELEASE EVALUATION FLR: = S 95!HOUR 5 <br /> SAMPLING INSPECTION FEE = S 951 F1016tT EXCt£D5 FEES <br /> PAID <br /> V/LL BE TO APPUeANT <br /> ALL GEES ARE OHI TME fK tomLV RATE. Tm <br /> OFFK,EUSEONLY AMaHNr�r�TYED CHECKt trF BY OAiERECEIvt� <br /> VICE REOt1ESre AICILr1YD <br /> SR <br /> ' EN n esz eiEVMED mrssioe7 <br />