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• SAN JOAQUIN COUNT Y <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 East Weber Avenue, 3`a Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5" floor): (209) 468-3433 Web: www.s'igov.org/ehd <br />FACILITY NAME FACILITY CONTACT NAME <br />Q t Wt ?I A*k <br />FACILITY ADDRESS SITE PHONE #WITH AREA CODE <br />-q 8'& 0 t= FC v D. <br />CITY STATE ZIP CODE # OF TANKS AT SITE <br />VIA PriA.T E—( k CA 5 3 3(. 1 3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />f, rL !Ac< <br />r — (M L CIA "IL Wear( -1 " <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />PIPING REPAIR FEE _ $285 / FACILITY (use for piping, under -dispenser containment, ect.) <br />TEMPORARY CLOSURE FEE _ $285 / FACILITY <br />.()• o Y, X02 f <br />(6 3}3— <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />-�-1 <br />2004 <br />/ S 6 Gl k Closure Installatio ep ' Retrofit <br />2006 <br />m <br />ACTIVE FACILITY <br />TANK ID # (s) : CLOSURE FEE _ $285 /TANK # TANKS X $285 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK RETROFIT REPAIR FEE _ $285 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />Z <br />$ <br />PIPING REPAIR FEE _ $285 / FACILITY (use for piping, under -dispenser containment, ect.) <br />TEMPORARY CLOSURE FEE _ $285 / FACILITY <br />TANK ID # (s) : <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE _ $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : CLOSURE FEE _ $285 /TANK # TANKS X $285 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK RETROFIT REPAIR FEE _ $285 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />Z <br />$ <br />PIPING REPAIR FEE _ $285 / FACILITY (use for piping, under -dispenser containment, ect.) <br />TEMPORARY CLOSURE FEE _ $285 / FACILITY <br />TANK ID # (s) : <br />ki-LATION PLAN CHEC <br />Check and Construction <br />TANK ID # (s) : <br />CHECK FEE _ $760 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />g <br />TANK RETROFIT REPAIR FEE _ $285 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />Z <br />$ <br />PIPING REPAIR FEE _ $285 / FACILITY (use for piping, under -dispenser containment, ect.) <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07128106) <br />