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d f ey . -k!y "'w' • to xt t i') <br />{ y < <br />41 <br />ld � f �4 r' d f i <br />10 1 �,i. I ♦ f l 9 P <br />� a t <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax. (209) 468-3433 Web: www.sigov.org/ehd <br />ArrLIUAN I MILLING NAME APPLICANT CONTACT NAME <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />Z.5tt6 <br />CITY STATE ZIP CODE clur.I F wn0 u r., o= <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 />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON I <br />PERMA ENT CLOSURE <br />Removal or Permitted Closure in Place) <br />TANK ID # s `. <br />TEMPORARY CLOSI <br />Plan RGviewand Ins <br />TANK ID # (s) : <br />INSTALLATION PLAI <br />Plan Check and Cons <br />TANK ID # (s) i <br />ICC # <br />2007 12008 1 2009 2010 t 2011 <br />RY IN A CUP) <br />FEE $375/ <br />PLAN <br />VK I # TANKS X $375 = <br />E = $375 / FACILITY I $ <br />=$1,000/FACILITY <br />MISCELLANEOUS ---- <br />TRANSFER FEE <br />CONSULTATION FEE OUR - <br />UNAUTHORIZED -6= <br />_. HOUR- <br />UNAUTHORIZED-RELEASEEVALUATION FEE =.$125/HOUR <br />SAMPLING INSPECTION FEE <br />_ $ 125/ HOUR <br />-ALL FEES -ARE BASED -ON THE -$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT, <br />TOTAL AMOUNT DUE <br />OFFICE USE ONLY $ <br />SERVICE REQUEST # FACILITY ID --AMOUN'i RECEIVED CHECK #e <br />RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 0811111 by KF) <br />z <br />