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SAN _ JOAQUIN Environmental Health Department <br /> COUNTY <br /> 1 . <br /> F COUTY N FACILITY CONTACT NAME <br /> Ect <br /> acicweld <br /> P � DW �, l_ /1 PICO U ``'' ( �f SITE PHONE z Yam AREA <br /> E <br /> CITY (/LZ1� ZIP CODE E OF TANKS AT 4RE <br /> LUNl3 NAME APPLIICAKT CONTACT NAME <br /> NA <br /> APPLICANT MAILWGADDRESS APPUCANTPHONE 01WF AREACODE <br /> 41 i Y ; ATE 21P CODE CIRCLE WORK TO BE DONE CONTRACTOR [CC <br /> - <br /> c4aA.e tratatfir;ori �r R.+I�vra <br /> ACTIVE FACK Y <br /> UST FEES = 5360 1 2014 2015 ' UST MSS 2016 UST FiMS - <br /> (Fa ltrisi a S383 0 ;841 2017 V 961 Fa loty 2018 S <br /> reek) + ST3tt�ank Facility + $961 Facitfty • <br /> o tw ISt $13Wank Faeirly4 S22=ankl <br /> S152lfank <br /> Doubts Wd 117az <br /> Compilant UST <br /> FEES = $650 <br /> Tank P - R-- N01ty 12200TAnk <br /> A "screed for S <br /> Unreported Tank% ' <br /> {Rased on h„nuat <br /> Perry Fngs) - <br /> TANK SURCWGE = $20 t TANK S <br /> ST ATE 9UROtARGE FOR CACIUTIES Noy ALREADY ON INVENTORY 14 A CUPA PN RAM OS AW FACS.ITY $ <br /> PERMANEXTSLOSURE <br /> tRemo LAI or Penatted Clawre In PMor) <br /> TANK IO 0 (s) _ I CLOSURE FCC = S4561 TANK l z TAW$ % $ 156 = S <br /> TgNPORMY CLOSURE <br /> Re"m and Im <br /> TANK IDS p) : TE Y C.LOSUTM FEE - S4561 FAG7UTY S <br /> IWSMALUAW PLAN CMECK <br /> (Plan Crx:k and Cowinxt m �i:PeUia•KI <br /> TANK D z M : PLAN 0CUK FEE = 53,0401 FACILITY S <br /> REPAIR PLAN CMlCK <br /> TANK D s (S) <br /> TAW RETROFIT REPAIR FrE - S4561 FAWUTY (tM fOr Mn" egWINTICrK, Cold start., EVR upgradne, S <br /> Sp41duckeix• <br /> PV4NG REPAIR FEE - $4561 FACJUTY luso ; d.r d, S <br /> _ ng: sponsor oontsirunmt�_ <br /> WSCQLLANEOUS <br /> TRANSFER FEE = $ 25 $ <br /> CONFATATKm FEF - S 1S2tHOUR _ 5 <br /> t1111A1 &0 RFLE.A52 EVA AAT10N FEF - S I521 HOUR $ <br /> SMIPLING 94SPECTM FEE - S 1S HOLOR s <br /> FEUARrv^Zftu0wTME $112WWRLYRATE. VWTM4r EXenens FEEtI tem WLL BE BX to Tp AP . <br /> TOTAL AMOUNT DUE Ys�] <br /> OFFICE USE ONLY <br /> SER waplpFST aEFCr1rr r D <br /> Rop1I;T) tY pATE cai<+ED <br /> _ JNTRFCxcveo otCGK • N <br /> 1888 E- Haratton Avenue ( Stockton, Culdomia 052051 T 209 458 .34201 F 209 s16"1313 wwdr_ ijcchd Com <br />