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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street; Stockton, CA 95202-3029 . <br />Telephone: (209) 468-3420 Fay (209),468-3433 Web: wwiv.sjgov.orgy/ehd <br />L 16t HT LCTa ",_ <br />APPLICANT MAILING ADDRESS <br />Wi fir, <br />CITY STATE ZIP <br />a + <br />r <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1' TANK (2005-200-A <br />•_-- -$O=FSE INCLUDES E9Ctl II�LFFF + �.I ANK(2008,201 ( <br />125 PER TANK AFTER _. <br />t 1�I hr <br />APP ANT PHONE # WITH AREA CODE <br />4te I -Ce37 <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />Closure Instatiatio Re 'r Retrofit r <br />--- <br />2005 2006 1 2007 1.2008 2009 209 Q.. <br />TANK SURCHARGE= $15 /TANK <br />STATE SURCHARGE FOR FACILMES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY $ <br />REPAIR PLAN CHECK <br />rTANK(s): <br />C)RTJ3EPAIR-1=EE $366 !-FAGILftY useformonftonn u' mer <br />{ --9-e9 ip .01 bucketssm a-___ 1 FEE _ $366 / FACILITY use for ipiri ; under-dispens <br />e <br />F <br />f. <br />;q. <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street; Stockton, CA 95202-3029 . <br />Telephone: (209) 468-3420 Fay (209),468-3433 Web: wwiv.sjgov.orgy/ehd <br />L 16t HT LCTa ",_ <br />APPLICANT MAILING ADDRESS <br />Wi fir, <br />CITY STATE ZIP <br />a + <br />r <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1' TANK (2005-200-A <br />•_-- -$O=FSE INCLUDES E9Ctl II�LFFF + �.I ANK(2008,201 ( <br />125 PER TANK AFTER _. <br />t 1�I hr <br />APP ANT PHONE # WITH AREA CODE <br />4te I -Ce37 <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />Closure Instatiatio Re 'r Retrofit r <br />--- <br />2005 2006 1 2007 1.2008 2009 209 Q.. <br />TANK SURCHARGE= $15 /TANK <br />STATE SURCHARGE FOR FACILMES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY $ <br />REPAIR PLAN CHECK <br />rTANK(s): <br />C)RTJ3EPAIR-1=EE $366 !-FAGILftY useformonftonn u' mer <br />{ --9-e9 ip .01 bucketssm a-___ 1 FEE _ $366 / FACILITY use for ipiri ; under-dispens <br />