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08/21/2006 15:54 46$38 ENVIRONMENTAL LTH <br /> • PAGE 01 <br /> SAN�144QXM�C-OUM Y. <br /> E23VIRONMENTi AL HEALT.(i DEPAxTmENT. <br /> 304 East Weber Avenue,3'd Floor,Stockton,CA 95202.2708 <br /> Tekpkone.(209)469-3420 .Fax(.1 floor):(209 68-3433 Web:www.s' ov.or chd <br /> FA ILFIY NAMEFACgdTY CONTACT NAME <br /> nu t <br /> _ . <br /> FACILITY ADDRESS SITE PHONE 0 WITH AREA CODE <br /> CITY STATE ZIPCO #OF TANKS AT SITE <br /> CA <br /> APPLICANT OLLING NAME I APPLICANT CONTACT NAME <br /> 0 <br /> APPLICANT MAILING ADDRESS I APPLICAW PHONE#WITH AREA CODE <br /> t <br /> CITY STATE I ZIP CODE -CIRCLE WORK TO HE DONE I CONTRACTOR ICC 0 <br /> • I � � -�---�. i /'1 � �� t C�L•.o �stSF.:t...'"^. P.�~ ,.e:'011t <br /> ACTWE FACILITY <br /> SSWFEE INCLUDES FACILITY FEE+1 TANK 2001 2002 2003 2004 2005 2006 <br /> 4125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILfnES NOT ALREADY ON INVENTORY IN A COPA PROGRAM--W4.00/FACILITY $ <br /> P RMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK 101k(s): CLOSURE FEE=$285/TANK #TANKS X S285= <br /> TEMPORARY CLOSURE <br /> (Plan Revlaw and to Coons <br /> . -TEMPORARY CLOSURE FEE=$285/FACILITY <br /> INS LLAT10N PLAN CHECK <br /> Plan Chack and Construc8an Inspections) <br /> TANK 10#(s): PLAN CHECK FEE=5760/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE' $285/FACILITY use formonitorin sill buckets,tank sumps,misc. <br /> PWING REPAIR FEE =$285/FACIUTY use for piping,under er Containment,cam. <br /> MISCELLANEOUS <br /> S <br /> TRANSFER FEE = S 20 <br /> CONSULTATION FEE - SSW HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATK}N FEE =S 95/Ii)UR <br /> SAMPLING INSPECTION FEE = S 9S1 HOUR <br /> ALL.FEES.AR6 amEo ON TmE 595 HOURLY RATE. TIME THAT EKCEEOS FEES PAID Wa.L 8E MUED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 0 FAdmy ID I AMOUNT RECEIVED CHECKS 1 RECEIVIM BY ®AYE RECEIVEC <br /> SR <br /> EH 23 032(REVISED 07/2/1081 <br />