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0 SAN JOAQUIN COUNTI' 0 FILE COP Y <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Far: (209) 468-3433 Web: www.sieoY.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />`i 'LC. 177�61 G 147 <br />SM t T1^( <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />1535 )E.' PEsCIA i)52O AJ6. <br />Zcrl$3� i3;D a <br />CITY <br />STATE <br />ZIP CODEI <br /># OF TANKS AT SITE <br />1 fLa Gif <br />CA <br />9 S3 a Ll <br />Im r -At I' C- E <br />APPLICANT BILLING NAME <br />TANK ID # s : <br />APPLICANT CONTACT NAME <br />Gov LSLI Q,:�(71 /a1664AI4G 1 P3G. <br />ScotT cAU 6y <br />APPLICANT MAILING ADDRESS <br />2006 <br />APPLICANT PHONE # WITH AREA CODE <br />21.oZS N6wPo,L'7 R-bi ikq-L1S(o <br />qC1 SZ2 - SI10 <br />CITY <br />ISTATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Im r -At I' C- E <br />GA <br />9tr'W4 <br />Closure Installation Repatr ReM <br />I SZSH "1--cU <br />ACTIVE FACILITY <br />TANK ID # s : <br />$500 FEE INCLUDES FACILITY FEE+ 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008) <br />$125 PER TANK AFTER FIRST TANK <br />2003 <br />2004 <br />2005 <br />2006 <br />200 7 <br />2008 <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$15/TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.001 FACILITY <br />Is <br />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s : <br />CLOSURE FEE = S294 / TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />REPAIR PLAN CHECK <br />RECENED BY DATE RECEVED <br />TANKID#(s): <br />TANK RETROFIT REPAIR FEE = $294 / FACILITYuse for monitorin <br />( g equipment, cold starts, EVR upgrades, <br />$ <br />ill buckets, sumps, mise. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 981 HOUR <br />PIPING REPAIR FEE = $294 / FACILITY use for piping, under -dispenser containment, act. <br />$ <br />MISCELLANEOUS <br />RECENED BY DATE RECEVED <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 98/ HOUR 2017 <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 981 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 9& HOUR - <br />AI 1 FFFR ERF RAQFn n. TUC a ..rn,In y n. x...v �...: cvrv..... ���.. ...... ...... ... _ _ <br />$ <br />OFFICE USE ONLY <br />SERNCE REQUEST # IFACILITY ID AMOUNT RECEIVED CHECK # <br />RECENED BY DATE RECEVED <br />SR <br />Fu"me.EEn!S n........ <br />