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ENVIRMWI' AL PEAU PAGE 01 <br /> P.0/21/2006 15:54 464013 SAN JOAQUINCOT'� <br /> EWMONMENTAL HEALTHTW _2708 <br /> 3D4 East arm AYMM 3"`Flow,Stockton, v. <br /> Tdepkerte:(209)468-3420 P�(3"I�r):(209)468-3433 Web:w�'w_.s31�°°`�` <br /> FACRITY ACT <br /> A NAME ' <br /> SITE WITH AREA CODE <br /> FACILITY ADDR S5 7/ � <br /> � #OF TANKS AT SITE <br /> P <br /> 8TATE <br /> CRY CA c/ - <br /> APPLIC CONTACT NAME <br /> APPLICANT BILLING / <br /> PHOW s AREA CODE <br /> APPLICANT MAILIN-rGADDRESS7//( STA ��/_ 3 3 /, C <br /> C/(� "- LP CODE CIRCLE WORK TO BE DONE <br /> CITY 6 Cbl MesUflm ReP* R�yrolfl <br /> NCTIVE FAcurY 200 2002 2003 20D4 2005 2006 <br /> S5W FEE INCLUDES FACILITY FEE')TAW $ <br /> 5125 PER TAW AFTER FIRST TANK $ <br /> 5 <br /> TANK PENALTY ASSESSm $ <br /> TANK SURCHARGE-$15 f TAN( �24.O0f FACILITY <br /> STATE SURtA1ARGE F'OR FACILITIES�T ALREAM <br /> ON INENIOR�'IN A CUPA PROGRAM <br /> PERMANENT C�GS•3RE - ' <br /> Fte or Pen'aw Cbs+re in Place 52851 TANK ft TAMCS X$2e5` <br /> CLOSURE F'�= <br /> TANKIDi 5 = ; <br /> TEMPORARY <br /> CL05NRE <br /> Rom and I <br /> TEMPORARY CLOSLM FEE_$2851 FACILITY <br /> TANK ID 0(s): <br /> INS A�TgN PLAN CHECK S <br /> Pian Cha&and ConslAK:rO1l PLHN CK FEE=51601 FAC)L.TTY <br /> TANK 11)#(s)-- <br /> R PLA"CHIEC <br /> TANK ID N 5 : Wdcals.tank .ndsc• <br /> TANK RETROFIT REPAIR FEE =52851 FACILffY use for <br /> use r7 � ,'�'� <br /> PIPING REPAIR FEE =$2851 FACILITY _ <br /> S <br /> M CE $ <br /> TRANSFER FEE _ $20 $ <br /> CON`,lL'LTATION FEE $9Y HOUR ' $ <br /> EVALUATION PEE = $961 HOUR <br /> UNAIR}K)RIZFD fCFLFASE - BE TOAppVCAltT- <br /> HDIR 1 YLL <br /> - SAMPUNO IFISPECT����LY WRTE Two T�EE0.5FfgS YAO <br /> ALL ARE <br /> BY MIE RECE{rW <br /> OFFICE USE ONLY AyprNr RECENEI a+ErAu - _ <br /> SERVICEREMESTO AGILITY II <br /> SR <br /> Ett 23 012 IREVBEO OTRaNa) <br />