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55517888 <br />Line 1 10:56:14 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazehon Ave., Stockton, C.A. 95205-6232 <br />Telephone: (209) 468-3420 Fact: (209) 468-3433 Web: www.sj,8ov.2rtehd <br />09-09-2013 6112 <br />FACILIITY NAME <br />FACILITY CONTACT NAME <br />/ <br />2008 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />i 0 ¢nom <br />2df 46 2 - t&1-7 <br />CIT' STATE <br />ZIP GORE # OF TANKS AT SITE <br />�C I CA <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />APPLICANT MAJUNG ADDRESS APPLICANT PHONE # WfTH AREA CODE <br />2008 <br />CITY STATE 21P CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Closure Instablon Repair Retrofit <br />2012 <br />TANK RETROFIT REPAIR FEE = $3751 FACILITY (use for mordtaring equipment, cold staffs, EVR upgrades, <br />= 5375 <br />WO <br />MISCELLANEOUS <br />M FEE INCLUDES FACILITY FEE + 1 TANK (2007-2006) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE a $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROD =fM.DW FACILITY <br />$ <br />TANK RETROFIT REPAIR FEE = $3751 FACILITY (use for mordtaring equipment, cold staffs, EVR upgrades, <br />= 5375 <br />WO <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $1251 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE 125( HOUR <br />•il GROw ♦Ot•n suTuc ��n�a <br />$ <br />_ -. __ - ___ _ . _ _- __ __-- __ _ _ _ __ a .� .. � �..-. . �...-. .-..� . • n r r.rwaa.rrr . rry r I'wM ev.ww f!Q irIwLGY I V lYPPw1YMR [. <br />TOTAL AMOUNT DUE Is <br />