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i f A i r ♦ 1 I t IA k- '� 1 � f• y f p ♦ � ,� A�@'[p_. f/k X 1 1 { r <br />r. f +� r r y f .1 / r � { M-� pM y y f rY � ♦/ f ♦ 1 { � f Y Yom" f� y i/ � f 1 <br />r 1 y yY -,f a:{ �, jr f r 1 R r/ f`.'+i y ♦Nr �, p 1 <br />SAN JOAQUIN COUNTY�V;01 <br />ENVIRONMENTAL HEALTH DEPARTMENT u <br />600 East Main Street, Stockton, CA 95202-3029 , <br />Telephone -(209) 468-3420 Fax. (209) 468-3433 Web: www.sj o� v.org/ehd <br />FACILITY NAME FACILITY CONTACT NAME <br />GlMrlI u 4 (2k) _ Ofli <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />915D lvv�tx'N K&'% U 112- Mg 2 <br />CITY STATE ZIP CODE # OF TANKS AT SITE <br />APPLICANT MAILING ADDRESS, <br />CA q <br />APPLICANT BILLING NAME <br />I APPLICANT CONTACT NAME f <br />E SE, a Z C, �SI I -PC. <br />�-AM wNMTE�. <br />APPLICANT MAILING ADDRESS, <br />APPLICANT PHONE # WITH AREA CODE <br />2.5Tj-sCouzv.)" <br />2010 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WOR K TO BE DONE <br />CONTRACTOR ICC # <br />C <br />-Closure--Installation Repair -Retrofit <br />TANK PENALTY ASSESSED I <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE = $375 / TANK # TANKS X $375 = <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$125 PER TANK AFTER FIRST TANK <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$ <br />TANK PENALTY ASSESSED I <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE = $375 / TANK # TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Ins ections <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $375 / FACILITY <br />INSTALLATIOI <br />(Plan Check an <br />TANK ID # (s) : <br />CHECK <br />PLAN CH <br />= $1,000 / FA( <br />OFFICE USE ONLY <br />