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SAN JOAQUIN COUNTY <br />ENVIRONMFNTAL HEALTH DEPARTMENT <br />1868 E. lIazelton Ave., Stockton, CA 95205-6232 <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 Web: www.siceltd.com <br />FACILITY NAME <br />FAC�I7Y CONTACT NAME <br />2q E0 F2 L <br />FIACILITYA SS <br />SITE PHONE#WITH AREA CODE <br />..-p. <br />16 1 dv ' �iil� tlltJrG �U <br />i <br />� Scl ' Q 1 <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />t Poi cA <br />5 <br />APPLICANT BILLING NAGS <br />APPLICANT CONTACT NAME <br />r 0 E5esd�-:`j GR.dUP t✓IC.. <br />(Ay It (J --,4LF-S <br />APPLICANT MAILING ADDRESS <br />45 5 LitcaS i�1lZ� <br />APPLICANT PHONE 8 WITH AREA CODE <br />27ZV� 9 <br />CRY ISTATE I ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />,s'k%1;I UC%N thWt / <br />Clusure Ins[a6atbn R air Retrofit <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK I— <br />I 2010 2011 ( 2012 2013 2014 <br />$130 PER TANK AFTER FIRST TANK <br />$ <br />I STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=435.00f FACILITY I ` I <br />TANK ID#(s): t .1 7_ <br />TANK RETROFIT REPAIR FEE = $390 / FACILITY (use formonitomig equlpment, cold starts, EVR upgrades, $ �� <br />ill buckets, sum s, mise) y� <br />PIPING REPAIR FEE = $390 / FACILITY (use for piping, under -dispenser containment, ect.) $ Itlr! <br />TOTAL AMOUNT DUE $ l pb <br />OFFICE USE ONLY <br />*16,4 k - <br />