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V ED <br />SAN JOAQUIN COUNTY AUG 13 2014 <br />ENVIROMI[ENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Avc , SLOckion, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: w,,vw.sicehd.com = \I\fiR�i�L HEALTF'I <br />FACILITY CONTACT NAME �? T ENT <br />FACILITY NAME <br />TANK ID # (s): <br />2009 <br />2010 <br />FACILITY ADDRESS <br />SITE PHONE #WITH AREA CODE <br />��� w, (�Ir'aW�;�-lyn� <br />05 8a-3— d--7 -3 <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />CA <br />53`7Lv <br />I <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />Q6%0o`-e PeAm1�av\ S1✓Yv, (� _ u.a�rxL -e Sunck-eZ <br />Iq 3o }y�se-S1, o -c.- 2A <br />000-- (Q[)�-q3�3 <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />ACTIVE FACILITY <br />TANK ID # (s): <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />2014 <br />spit buckets, sumps, misc. <br />5550 FEE INCLUDES FACILITY FEE+ 1 TANK <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY use for in , under-dis r. ser containment ed. <br />S13C PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 /TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00! FACILITY <br />PERMANENT CLOSURE <br />(Removal or Permitted Closure in Place) <br />TANK ID # (s): <br />CLOSURE FEE = $3901 TANK <br />#TANKS X $390 = <br />TEMPORARY CLOSURE <br />`Plan Review and Inspections) <br />TANK 10 # (s): TEMPORARY CLOSURE FEE = $3901 FACILITY <br />REPAIR PLAN CHECK <br />TANK IID # (s):. <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $390.i FACILITY (use for monitoring equipme d starts, EVR upgrades, <br />spit buckets, sumps, misc. <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY use for in , under-dis r. ser containment ed. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />CONSULTATION FEE = $ 130! HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 1301 HOUR <br />SAMPLING INSPECTION FEE _ $ 130! HOUR <br />ev 0u en 7n e001 Id -ANT <br />TOTAL AMOUNT DUE $ + <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECKS <br />RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 06-04-141 <br />9'd £9689V960Z =81011ed el9e11e21 eLt,:90 t, 6 £ b Fny <br />