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08/21/2006 15:54 4640138 ENVIRONMENTAL HEALTH PAGE 01 <br /> SAN JOAQUIN COUNTX0 . <br /> ENVIRONMENTAL HEAL'T'H DEPARTMENT <br /> 304 East Weber Avenue.3r1 Floor,Stockton,CA 95202-2708 <br /> retepkone:(209)458-3420 .Far(S"fX O:(201)468-3433 Webs www_silr0v.or,8/c1d <br /> AGILITY NAME FACRJTY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE# AREA CODE <br /> CITY I STATE ZIP CODE #OANKAT SITE <br /> CA Cl X20 C <br /> APPLICANT BILLING NAME ADPL T CONTACT NAIVE <br /> 1 I t, 0 mf YMfo(s <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE>r VYITH AREA CODE <br /> C:95 :Y Wt U�Airtno , CIh 4Q11-b <br /> CITY STATE ZIP CODE CIRCLE WORK TO RE DONE CONTRACTOR ICC!I <br /> Cio " Mst thin Repair Rewflt <br /> ACTIVE FACILITY s� <br /> 2001 2002 2003 2004 2005 2006 <br /> 5500 FEE INCLUDES FACILITY FEE;1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE_$15/TANK $ <br /> STATE SURCHARGE FOR FACILITES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Piave $ <br /> TANK ID# CLOSURE FEE=5285/ <br /> 5 : TANK #TANKS X_SMS- <br /> . <br /> TEMPORARY CLOSURE <br /> (Ptan Review and In Ctions $ <br /> -TANK-ID-#(s):--- TEMPORARY CLOSURE FEE=52851 FACILITY <br /> INS AU.ATlON PLAN CHECK <br /> Plan Check and CansKuct1 dion6 $ <br /> TANK ID#(s): PLAN CHECK ISE=ST601 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s : <br /> -----..___--- <br /> S ill buccal,.tank gum .misc. <br /> TANK RETROFIT REPAIR FEE _S2ft 1 FACILITY use for moM $ <br /> PIPING REPAIR FEE =$P$5J FACILITY use for °^ containment'c <br /> MISCELLANEOUS $ <br /> TRANSFER FEE ' S 20 $ <br /> CONSULTATION FEtc = S 95t HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S95/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = S S&HOUR <br /> ALL FEES ARE ED ON TRE 03 RbURLY RATE• TIME THAT W(CE163 FEES PAID wa.L BE ED TO�APAN�T. <br /> OFFICE USE ONLY <br /> CEIVED BY DATE RECEIYEO <br /> SERVICE R—SWESr• FACT WTY AMOUNT RECEIVED CHECK E RE <br /> SR <br /> EH 23 032/REviseo 07128M) <br />