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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 95202-3029 ephone: 1?09) 468-3420 Fax: (209) 468-3433 Web: A . n Y'Y MAINE FACILITY CONTACT NM Mirimar Valero B.S. Angle FACILITY ADDRESS ,I I C rH"Mr- �F VVI I n ruc=s+..vuc 1605 S EI Dorado St t Ct 0 CITY STATE ZIP CODE I # OF TANKS AT SITE Stockton CA 95206 ;PPUUANI UILLIPR7 VAMC OUR NAME APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE bC jNj 0 VL-A,r 2006 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # `^ CA `J" Closure Installation Repair Retrofit 5252923 -UT ACTIVE FACILITY TANK ID # s : CLOSURE FEE= $315 /TANK7 /TANK # TANKS X $315 = 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) $ $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009) $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED $ TANK SURCHARGE= $15 /TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM =$24.001 FACILITY PERMANENT CLOSURE Removal or Permitted Closure In Place TANK ID # s : CLOSURE FEE= $315 /TANK7 /TANK # TANKS X $315 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $315 / FACILITY TANK ID # (s) : I ^- •err rrrrc.r-r-�SQ40..__ I�ACIL �_ ANK ID # (s) OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 02!23109) TANK RETROFIT REPAIR FEE = $3151 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, 366.00 ill buckets, sumps. misa $366. $ PIPING REPAIR FEE = $315 ! FACILITY juse for piping, under -dispenser containment, ect. _ OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 02!23109)