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• ENVIRONMENTAL • <br /> � HEALTH DEPARTMENT . <br /> 6 600 East Main Street,Stockton,CA 95202-3029 <br /> Me.Phone.(209)468-3420 Faa~(209)468_3433 Web.wvk+w s MV 0re%hd <br /> r FACILITY NAME r <br /> i FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE VYITH CODE <br /> V 339 _ _. <br /> CITY <br /> STATE <br /> CA aP COPE OF TANKS AT SITE <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> LIC M �j <br /> 'APPLICANT MAILING ADDRESS APPLICANT PHONE a#WITH AREA CODE. <br /> _CITY STATE z1P CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closwe Installation R r RetrOftt <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+.1 TANK(2006-2097) 2006 2007 2008 2009'" 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(200&2011) . <br /> $125 PER.TANK AFTER FIRST.TANK $ <br /> TANK.P_ENALTYASSESSED <br /> -TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IISA COPA PROGRAM X49.00/FACILITY <br /> .PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place <br /> TANKID,# s CLOSURE FEE_$375/ <br /> TEMPOCLTANK #TANKS X$375= $ <br /> RARY OSURE <br /> Klan Review and in <br /> T#►NK ID#(s): TEMPORARY CLOSURE FEE_$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and ConshvcUon Ins ons <br /> -- - --... PLANGHE6K.FEE.=_$IUQQI FACILITY <br /> REPAIR PLAN CHECK <br /> • TANK 1p#(s): - _ . <br /> 77 <br /> A1�1K-t`ii'FROFiT RERAIR FSE $$7�7 F/l�I4CIY_(use_for men - _ <br /> buckets, mac. <br /> LILIAI�-REPAIR FEE 75=/FACIL'FTY - _ <br /> - ---- - <br /> kt�for ,colder --- corltablrrlerct,ect <br /> TRANSFER FEE -$25 <br /> t XjNSUVTATION tyEE $'125/HOUR 251 Hom <br /> _ <br /> SAMPLING INSPECTION FEE =S 12,5LHQ.UR . <br /> - <br /> -� BASE0 ON THE$125 HOURLY RATE TIME THAT IXCEEDS FEES PAb <br /> _ WILL BE BILLED TO APPLICANT. <br /> TC`I'JKKIT�IIOUNT At I <br /> -_ CE,USE_ONLY_ $ <br /> L <br /> VIGEREQUEST# -FACILffYID AMOUNT.RECEIVEQ ! <br /> CHECK IK RECEIVED BY DATE RECEIVED ! i <br /> i <br /> EH'23 D32{REVISED 08/1M lb <br /> YI(F) <br /> ' 1 <br />