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MAR -07-2007 08:03 Seruice Station Systems 408 938 8988 P.02. <br />0 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTII DFPARTMENT <br />304 East Weber Avenue, 3d Floor, Stockton, CA 95202-2708 <br />Telephone. (209) 468-3420 Fax (5`* floor): (209) 468-3433 Weh, AM�w�xo..vor �/ghd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />V -C' <br />2002 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />'®f <br />(ac li 478 -.7337 <br />I CITY STATE <br />ZIP CODE 9 OF TANKS AT SITE <br />L i -o to CA <br />qQ-17 I <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />V -C' <br />2002 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE 0 WITH AREA CODE <br />�gt) <br />(40�) Q1 -I-- IoO 3 9 <br />CITY STATE <br />CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC 9 <br />CZIP <br />-4f5 <br />C <br />Closure (Installation Repair Retrofit 0.1 <br />ACTIVE FACILITY <br />TANK ID #Lq); <br />CLOSURE FEE � $2:8,5:1 TANK <br />2002 <br />2003 <br />2004 <br />2005-2006 <br />2007 <br />$500 FEE INCLUQE5 FACILITY FEE + I TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE z $ 95 / HOUR <br />SAMPLING INSPECTION FEE = $ 95/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TANK PENALTY A$SESSED <br />$ <br />TANK SURCHARGE = $151 TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM =$24.001 FACILITY <br />PERMANENT CLOSURE <br />(Removal or Permitted Closure in Place) <br />TANK ID #Lq); <br />CLOSURE FEE � $2:8,5:1 TANK <br /># TANKS X $285 <br />TEMPORARY CLOSURE <br />I (Plan Review and Inspections) <br />TANK ID # (5) ; <br />I TEMPORARY CLOSURE FEE _ $285 / FACILITY <br />REPAIRPLANCHFCK <br />TANK ID # (a); <br />TANK RETROFIT REPAIR FEE _ $2851 FACILITY use for monitoring a92mentspill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $2851 FACILITY use for piping, under -dispenser containment, act. <br />MISCELLANEOUS <br />TRAN$F5F7 FEE $20 <br />CONSULTATION FEE $951 HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE z $ 95 / HOUR <br />SAMPLING INSPECTION FEE = $ 95/ HOUR <br />ALL 111:9iAllr 15A*CWVR 1 MC pV* R%JUKL.T MAI C. jamr 1rmi r^%,,rr—uzp rrr—o rmu YM.L Or— DJLLCU I WMrrU�. I - <br />