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� qty y A, .y. i-�=t !► I VAN&et !r <br />If <br />1-7 <br />SAN J9AAQUIN COUNTY + tiJ I t <br />j ENVIltONMEWTAL HEAL TH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 A <br />Telephone: (209) 468-3420 Fax. (2q9) 468-3433 Web: www s� ov or /ehd p e <br />+ __ <br />I FACILITY NAME FACILITY CONTACT NAME <br />I <br />FACILITY ADDRESS �1Q <br />SITE PHONE # WITH AREA CODE <br />r <br />H(A e <br />_ <br />„ t CITY STATE -ZIP CODE # OF TANKS AT SITE <br />• CA IT <br />4 APPLICANT BILLING NAME <br />APPLIGANT_COIIITACTHAME .. _ <br />APPLICANT MAILING AbDRESS APPLICANT PHONE #WITH AREA CODE <br />CITY <br />STATE ZIP CODE <br />CIRC LE WORkI -TO-B .DONE -_-.......CONTRACTOR <br />--_ <br />Closure Installation Re air Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) 2006 2007 2008 2009 2010 2011 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011). <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED $ <br />TANK SURCHARGE = $15 /TANK $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PRnraenA -tete 11, <br />.-.....nlwAv rulry GtiG4K -_ <br />Plen Check and Construction Ins ections <br />TANK ID # (s) : PLAN CHECK FEE _ $1,000 / FACILITY $ <br />REPAIR PLAN CWECK <br />TANK ID # (s) - <br />TANK RETROFIT REPAIR FEE _ $375 /FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />_____._____�__ s Ili, buckets, sum s mise. <br />PIPING REPAIR FEE $375 /FACILITY use'for- I `in , under4s enser containment, ect, $ <br />-- -� --- <br />77. <br />_. <br />IUNAUTHORI'ZED-kELEA8E'tVALUAT16ki-�- <br />ISCELLANEOUS -- <br />RANSFER FEE <br />UEE-=.$125/HOUR.UR <br />.. ---MPLING INSPECTION: FEE <br />.--ALL FEES -ARE BASED ON THE-S1zb HOuai y w/emOURn.= $ <br />3 <br />