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08/21f2006 15:54 464 <br /> ENVIRONMENTAL HEALTH PAGE 01 <br /> IfCOUSAN JOAQtTTN <br /> M <br /> x <br /> ENvMONMENCAL HEALTH DEPA[C <br /> 304 East Webs Avenue.3"Float,Stockton,CA 95202-2708 <br /> Tetepkene:(209)468-3420 Fmc(S"`.1"r):(209)468-3433 Web:—Www-s Ov arg/ <br /> FACILITY A�li/1ME <br /> ACILIiY E <br /> PHONE>ie <br /> FACILITY ADDRESS ; <br /> CITY ��O .. � CODE <br /> ,..' <br /> STATE <br /> 9i <br /> CONTACT NAMt: <br /> APP BLLLW0 NAME <br /> APPtJC S wtm AREA CODE <br /> APPL <br /> I <br /> CANT MAIL /_ 23�- <br /> Z!P CODE CIRCLE YYORK TO BE DONE ICC CONTRACTOR ICC P <br /> CITY STATE <br /> }3' Cip�pe k�st0}atlon Repair RelroM <br /> ACTIVE FACLLITIf2004 2005 200E <br /> 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSEt) $ <br /> SIS I TANK $ <br /> TANK SURCHARGE. �4,pplFAC <br /> ILITY <br /> Y ON WVEWORY IN A CUPA PROGRAM <br /> STATE SI�iARGE FOR Fp,CIi.T[tES NOT ALRFAD <br /> PER $ <br /> or Permit0e I C>Closurein Plaice <br /> CLOSURE FE =S !TANK S TANGS X S2@5 <br /> TANK 10� s <br /> TEMPORARY CLOSURE $ <br /> an Rem and In FEE=s236 E FACILITY <br /> �MPO}�tY{X,OSURE <br /> TANK ID#(s): <br /> IN ALII►T10N Pt ANCK $ <br /> Plan Check and Corksi �tkI 'ons PLAN CHECK FEE=S760 I FACILITY <br /> TANK 10#(s) <br /> REPAIR PLAN CCK R <br /> TANi(tt3$ Sicefs.Wm-SVM,' �— $ <br /> TANK RETROFIT REPAIR M $2.851 FACILE_ use <br /> PIPING REPAIR FEE =5285 t FACILITY <br /> use for ''twat <br /> M CE <br /> $ <br /> TRA.NVER EEE = S20 <br /> a SWpOUR - <br /> CONsL:8&TATION FEE c <br /> E1/ALUATK}N FEE = S qa t H WR y J <br /> i.iNA41TF+lORIZEO REL�E _-•�___��..._,,..._--- <br /> SAtAPLiNG IT PELT FEE = S 951 HiOL1R T r FSS pAp 1lMO.L TO APPIl�1NT <br /> ALL FEES ARE <br /> ai Sim �pIlRLY RAZE SSE <br /> OFFICE USE Ol+K.YBy <br /> S&RVICEREQUEST ACIUTY10 <br /> SR <br /> rs 032 Ito oTrt>►I�1 <br />