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01/18/200S 14:06 4640138 ENVIRONMEt,4TAL HEALTH PAGE 08 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMIP.NTAI,HEAuFf DEPARTIMENT <br /> 304 East Weber Avenue,3rd Floor,Stockton,CA 95202-2709 <br /> Mephone:(209)468-3420 Fav(fofloor):(209)468-3433 Web. www.s-pm.qrp/qhd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY—ADORESS SITE PHONE 0 NTH AREA CODE <br /> CITY I STATE I ZCODE0 OFT KS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Ike—ok4t <br /> f-fdAkT MAIURNG ADDRESS APPLICANT PHONE#NTH AREA CODE <br /> V0 <br /> CITY STATE ZIP COCE CIRCLE WORK TO BE DONE CONTRACTOR ICG 0 <br /> r- Closure Installatio par) <br /> Retro* <br /> ACTM FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE e$151 TANK $ <br /> LATE SURCHARGE FOR FACILITIES tN402TL&ALRpQY qN INVENTORY IN A CUPA PROGRAM=1124.001 FACILITY_ <br /> PBRUANENTCLOSURE <br /> Removal or Penitted Closure In Place) $ <br /> TANK 121A SURE FEE 2$27 0 TANKS X SM <br /> TEMPORARY CLOSURE <br /> (Plan Raytiew�and ln�sctloris) <br /> L TANK 10*(s): TEMPORARY CLOSURE FEE $2791 FACILITY <br /> I STALLATION PLAN CHECK <br /> (Plan Cheek and Construction Ins ctlons -- <br /> $ <br /> TANK ID 111(0); PLAN CI1EGi(FEE m$7441 FACILITY <br /> PAIR PLAN CHECK <br /> "No *,q +-71f <br /> TANK n±lq ���: $ <br /> TANK RETROFIT REPAIR FEE $27gFACILITY (use for maniltorin,, 77 <br /> [PIPING REPAIR FEE $27 ng,under-OW-pemer 00nIalm-nW,'I <br /> -MISCELLANEOUS <br /> -MANSFER FEE 2_0 <br /> _gMgTH0RjZE0 RELEASE EVALUATION FEE S 92 1 HOUR $ <br /> SAMPLING INSPECTION FEE = S 031 HOUR <br /> ALL POPS ARE BARE ON T 8 jWjjfcLT RAPE. THAT UQA"T- <br /> OFFICE USE ONILY- <br /> I OUNT <br /> —_-R—VIG-fi-KF-F .10 1 <br /> --A ILJ 10 AM <br /> IEN 23 032 CRENA 5 07J2245) <br />