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MR= <br />�T <br />9 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTM <br />East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone. (209) 468-3420 Fax (P floor): (209) 468-3433 Web: www-sieov orWe'hd <br />FACILITY CONTACT NAME <br />I <br />Closure <br />i® a U%JN 1 Hl. l IMArAI—- - <br />r w4ms <br />NT PHONE # WITH AREA CODE <br />" t7 <br />E WORK TO BE DONE <br />CONTRACTOR ICC # <br />nstallation �Retrofit <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK 2002 2003 2004 2005 2006 2007 <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />(Removal or Permitted Closure in Place) <br />ANK ID # <br />(Plan Review and <br />TANK ID # (s) : <br />FEE = $285 / TANK I # TANKS X $285 = <br />FEE = $285 / FACILITY <br />OFFICE USE ONLY <br />