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08/21/2006 15:54 4640138 ENVIRONMENTAL HEALTH PAGE 01 <br /> SAN JOAQUIN COUNTY <br /> U ENVIRONMENTAL HEALTH DEPARTWNT—� <br /> 304 East Weber Avenue.3rd Floor,Stockton,CA 95202-2706 <br /> Telephone:(209)466-3420 Pat(P Jloor):(209)468-3433 Web:www si>Ov 01I/chd <br /> AC Lff V NAME F CONTACT NAME <br /> FACILITY ADDRESS - SITE PHONE 5 CODE <br /> 3 <br /> m. STATE 4iP CODE SOF TANKS AT SITE <br /> 1 <br /> APPLICANT BLARNAME APPLICANT CONTACT NAME <br /> \� <br /> ` <br /> APPLICANT MADD <br /> AILING RESS AP ONES WITH AREA CODE <br /> �- 33 <br /> CIT Y STATE ZIP COVE CIRCLE WORT TO BE DONE CONRRACTOR ICC N <br /> Closure kista5a -ilepalr ovum <br /> ACItYE FACILITY <br /> 2001 2002 2003 2004 2005 2006 <br /> SSW FIB:INCLUDES FACILITY FEE*1 TANK $ <br /> $126 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED - $ <br /> TANKSURCHARGE-5151TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM S24.001 FACILITY <br /> P ANEKTCLOSURE <br /> moral a PemriRed Closure A Place $ <br /> TANK ID O s : <br /> CLOSURE FEE=5285!TANK /TANTS X SM5 <br /> TEMPORARY CLOSURE <br /> an RwAaw and ons $ <br /> TEMPORARY CLOSURE FEE=$205/FACILITY <br /> MS ALLATION PLAN CHECK <br /> Plan Chadc and CanswLllDD 1 'ons $ <br /> TANK 10 M(a): PLAN CHECK FEE_$160/FACILITY <br /> R AIR PLAN CHECK <br /> TANK I)K(s): Ang $ <br /> TANK RETROFff REPAIR FEE =$285/FACILITY uce tot <br /> I S 6uceats,tank ,ndsc. -$ <br /> PIPING REPAIR FEE =5205/FACILIT' <br /> use for . <br /> under or opmaam�elll aci. <br /> III <br /> ANEOUS $ <br /> TRANSFER FEE ' $20 $ <br /> CONSULTATON FEE a S 951 HOUR S <br /> UNAUTHORIZFU RELEASE EVALUATION FEE = S 951 HOUR $ <br /> SAMPLING IH,SPECiKN1 FEE = 5951 HOUR TD AppUCANT. <br /> ALL FEES N7E EA DN TME S&S NDURLY RATE TIME THAT EXCEEDSFEES PND WILL RE <br /> OFFICE USE ONLY <br /> D CHECKS RECENED BY DATE RECENT <br /> VK:E REQUESTe FACIL17Ym a1AO1INT RECEIVE <br /> SR <br /> EM t1 OaZ/REVDED 072aNa) <br />