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08/21/2006 15:54 4640138 ENVIRONMENTAL HEALTH PAGE 01 <br /> • SAN JOAQUIN'COUN Y <br /> ENWRONMENTAL HEALTH DEPAKTMENT <br /> 304 East Weber Avenue.3 d Flom Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Far(P floor):(209)468-3433 Web.www_s' ov.or chd <br /> FACILITY NAME FACILITY C ACT NAME <br /> FACMfffADDREIS 51TE 11 iNITN AREA CODE <br /> 'Alov�� <br /> CITY STATE �p(C`gQE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE S WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO 8E DONE CONTRACTOR K:C w <br /> Closurm IosbUtlon Repair Retrofit <br /> ACTIVE FACILITY <br /> 2001 2002 2003 2004 2005 2006 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=524.00/FACILITY <br /> p RMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> LANK ID# s CLOSURE FEE=$2851 TANK #TANKS X$285 c <br /> TEMPORARY CLOSURE <br /> an Revlaw and InsimcdomnS $ <br /> - .- - TEMPORARY CLOSURE FEE_$285/FACILITY <br /> -TANK ID-0(a):- <br /> IN AL.lAT1ON PLAN CHECK <br /> Plan Check and ConsWctlan I i0nb $ <br /> TANK ID#(s): PLAN CHECK FEE=5760 I FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> to,tank sumP5,mc. <br /> _-- budcais <br /> TANK RETROFIT REPAIR FEE =5285 I FACILITY use Iormoriit $ <br /> PIPING REPAIR FEE _$285/FACILITY use tw undue CO"ta� t <br /> MISCELLANEOUS $ <br /> TRANSFER FEE _ S $ <br /> CONSULTATION FEE = S 951 WOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 951 HOUR $ <br /> SAMPLING INSPECTION FEE = S 951 HOUR <br /> ALL FEES ARE ED ON TFiE 5115110URLY RATE- SINE THAT pCCEE0.S=FEESPAID WILL BE lTtILED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST t FACT WTY ID AMOUNT tnCE1VED CHECK# RECf3NED 9Y DATE RECEIVE <br /> SR <br /> 6H 23 832 4REVISED 072&06) <br />