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n..aanna.an ainrtucla�'1' <br /> 600 East Main Strcet,Stockton,CA 95202-3029 <br /> € - Telephone:(209)468-3420 Far:(209)468-3433 Wb.- <br /> FACILITY <br /> eb:FACILfIY NAME FACILITY CONTACT NAME <br /> c ev d <br /> FACILITY ADDRESS SPE PHO #WITH AREA CODE <br /> ED H <br /> C(iY STATE ZIP CO E # TANKS AT SITE <br /> An CA <br /> APPLICAN7T-lBIIli NAME APPLICANT <br /> �rCONTACT <br /> NAM <br /> E <br /> Ll/ E l l l yL <br /> APPLICANT MAILING ADDRESS .APPLICANT MUNE#WITH AREA CODE. <br /> "'r Situ ZIP CODE CIRCLE WORK BE DONE CONTRACTOR ICC# <br /> . Closure Irmmoanon R it Retrofit <br /> ACTIVE FACILITY - <br /> _ $500 FEE INCLUDES FACILITY FEE+1 TANK(2001x2007) 2008 2007 2008 2009` 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(200&2011) - <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY-ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOTALREADY ON INVENTORY IIT A CUPA PROGRAM X49.00/FACILITY � $ <br /> P.ERMANENTCLOSURE . <br /> Removal or Permitted Closure In Place <br /> TANK ID#(s): CLOSURE FEE=$375/TANK <br /> T #TANKSX$375= $ <br /> EMPORARYCLOSURE <br /> -Rlan Review and Inspections) <br /> TANK ID#:(s):. TEMPORARY CLOSURE FEE- --$ <br /> -5375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construc8on Ins ectIons <br /> - .. T7uylsl0.6'181. . . . _L... .. . _PLAN CHECK FEE,$1.0001 FACli MY <br /> - REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> "._. _- 1ICH"ElROFCfRER7 FEE $a7,57 �"Ci.ILI�SC-_(usetormonuonn - - <br /> -- -_ -- BEquIPmeYIk"Cold stSPI��VR'1 pTW�g-' <br /> -=•ze - — .__._. <br /> . b buckets,sum misc. <br /> PIPING:REPAIR FEE=$375/FACILITY' use for `;ondervdispenser containment, $ - <br /> TRANSFER FEE _ $25 _. <br /> CONSULTATION iH� - $125/HOUR - <br /> .. .- <br /> -7NAlITNORIZ.E6RECFASEE�ALUAT]ON <br /> I <br /> SAMPLING INSPECTION FEE =-$125/HOUR <br /> - ALL FEES BASE ON THE$125 HOURLY RATE TIME THATE%CEEDS FEES PAID MILL BE BILLED TO APPI.K;AN7 _ <br /> TOTAL TUiO7 NT DUE ; <br /> OFFICE USE ONLY - I <br /> -SERVICE REGUESTf -FACILIfYN AMOUNT RECEIVED CHECKS - <br /> RECEIVED BY DATE RECEIVED <br /> . -EH'23 D72(REVISED OS/iHt 4Y K� f. i <br />