Laserfiche WebLink
:',/17/2@e8 08:24 208,16-8 ENVIRONMENTAL. �Jr` TH PAGE 06/07 <br /> SAN JAAQ13N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)469-3420 Frcz.' (209)468-3433 Web:www_siiPoy-.0 ell—d <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY 3TATE ZIP CODE #OF TANKS AT StTE <br /> �Q CA <br /> APPLICANT 6 NAME / APPUCANT CONTACT NAME <br /> -7 <br /> APPLICANT MAJUNG ADDRESS APPLICANT PHONE#VATH AREA CODE <br /> d(5� r, 'D'o <br /> CITY STATE ZIP CODE CIRCK TO BE DONE CONTRACTOR ICC# <br /> EQeInstallation ep6f Retrofit <br /> E <br /> AC-PVF-FACILITY <br /> 2003 2004 2005 2006 247 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15[TANK <br /> STATE SURCHARGE FOR FAG ILCTIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$24.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID# s : CLOSURE FEE=$294/TANK #TANKS X$294= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s). TEMPORARY CLOSURE FEE=$294!FACILITY <br /> INSTALLATION PLAN CHECK <br /> P#on Check and Conotrucbon Inspections) <br /> TANK 10#(s): I PLAN CHECK FEE=$784 l FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s)' <br /> $ <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitcxing egWptrient,cold starts,EVR upgrades, <br /> s ill buckets sum ,mise, <br /> PIPING REPAIR FEE _$294 1 FAGtLiTY use for plplrq,under-dis nser containment,ect- <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE w $20 <br /> CONSULTATION FEE = $951 HOUR <br /> UNAUTHCRIZED RELEA5E EVALUATION FEE = $991 HOUR <br /> SAMPLING INSPECTION FEE = S 981 HOUR <br /> ALL V*93 ARE BASED ON THE$Aa HOURLY RATE. TWE THAT ExcEED3 FEES PAID WILL 6E BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> gERVICE REQUEST* FAt;1LITY rD AMOUNT RECEIVED CHECK R RECEIVED BY DATE RECEIVED <br /> SIR <br /> EH 23 032(R"SED 121311071 <br />