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SAN XbA.QUIN COUNTY <br /> ENVIRONMBNPAI.HEALTH DEPARTMENT <br /> 304 Fast Webcr Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> relepfaome:(209)468-3420 Fax(rjloor):(209)4683433 Web:www•s' ,ov.ors/elad._ <br /> FACILITY NAME FACILITY CONTACT NAME <br /> ut <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> fSe cf 1~ <br /> CITY STATE ZIP CODE J #OF TAN KS AT SITE <br /> ..f-c LLIC <br /> APPLICANT BILLING+NAME APPLICANT CONTACT NAME <br /> APPLICANT.MAILING ADDRESS APPLICANT PHONE#WIT14 AREA CODE <br /> 141i t <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> C i/ Closure Installation Retrofit - f <br /> ACTIVE FACILITY <br /> 2000 2009 2002 200$ 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE I TANK <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE®MI51 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA COPA PROGRAM m$24.001 FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or PormItted Closure in Piace <br /> TANK ID#(s): CLOSURE FEE $2791 TANK #TANKS X$274 a $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins coons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$2791 FACI LITY <br /> INSTALLATION PLAN CHECK <br /> Plan Chack and Construction Inspections) <br /> TANK ID 0(s): PLAN CHECK FEE_$7441 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s)-; <br /> TANK RETROFIT REPAIR FEE $2791 FACILITY Use for monitoring a ul ment.split buckets,tanksurn s,misc.) <br /> .•-�" PIPING REPAIR FEE d79!FACILITY Ama for Pipins.urea®rvdis ansar oontaiwwrit,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE. _ $20 <br /> CONSULTATION FEE = $93/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $SW HOUR <br /> ALL FEFSARE EASED ON THE$03 HOURLY RATE TIME THAT EXCEEDS FES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICIEUSE ONLY <br /> S <br /> IRVICE QUEST* FACIUTY lD AMOUNT RECEIVED cMECKo RECEIVED BY DATE RE"' <br /> J' <br /> SR <br /> EN 23 032(REVISED Q7 VOS) <br />