Laserfiche WebLink
SAN AJQUJN COUNTY ENVIRONMENTAL HEALTHI&ARTMENT <br /> ' UiNDERGRD STORAGE TANK PROGRAM J1WE WORKSHEET <br /> FACI I; NAME FACILITY COIJTACT NAME <br /> Fa I MY ADDRESS SITE P ONE?;WITH AREA CODE <br /> �­ 67 )a�/ q w 6, q <br /> CI t <br /> STATE ZIP CODE I #OF TANKS AT SITE <br /> CA <br /> P <br /> ANT BILLING NAME APPLICANT CONTACT NAME <br /> TE IV CONTRACTORS, INC. CARRIE MILLER <br /> NT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE5 WIGWAM DRIVE <br /> ( 209 ) 461 -6337 <br /> CITY ICA <br /> ZIP CODE CIRCLE WORK TO BE DONE: <br /> STOCKTON 95205 <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 20012002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK (5170)X(#lan)s? {si7o}x(#tanks) <br /> $125 PER TANK AFTER FIRST TANK _ <br /> - <br /> r TANK_- NAI-TYASSE;SED $ <br /> 1 ANK SiJR('I LARGE•=$J0.'TANK <br /> S it.+`.SURCHAR(;E;:()R Fi - LITIES POT ALREADY ON INVENTORY IN F ,',.JPA PROGR'.M S17 ,O FACILITY� $ — <br /> PEkr4_ VENT CLOSURE <br /> Removal or Permitted Closure in Place} <br /> TANK ID#(s): CLOSURE FEE_$2791 TANK #TANKS X$279= <br /> TEMPORARY CLOSURE �- <br /> (Y�L,•.' :F'V9e JJ:r!', dic.nPC:;ICnS <br /> �TEMPOR�ARY,_._tc;URE FFr $2 9 r FACIL_;t Y --- <br /> I?J:T�.°LATIOfa Pi ru'S .HEGK. --- — �.—, <br /> (P:Lir. "Fie 4 ,,d Gc,!;,:'­fiction in3nectiun,'� <br /> LAN CHECK FEEFACILI-I <br /> REF kiR <br /> T; NX i;ETRCPIT ieEPAIR FEL- $279 1 FACILITY (use fn-moni0ring equipm,nt,spill bucker,,tank sumps,mise) <br /> �PIPING! E_,' ;?: E{. _$279 F/,CP. FY (use forpiping,und�r�iis ei,:� ronta r,me•nt,ecL) <br /> _-- — ---a— — P <br /> '_TRANSrER FEE _ $20 <br /> -�" UL'ATION FEE__ 831 HOUR <br /> UNaLI'HGRIZEi iE'vA3L&,'ALiJATIONFF-C = $93/HOUR $ _—.— <br /> SAMPLING INSi-L-"l:HON FEEDE-_$531 HOUR � <br /> ALL FEES ARE BAS,=:D ON THE 593 H[1URLY RAi E. TIME TI-IAT EXCEEDS FEES PAla7 WIL'_ B;:LLED TO APPLICA'- — <br /> OFFICE USE ONLY <br /> SERVICE REQUEST <br /> — AMOUNT RECEIVCD <br /> — _ — CNF:£K# _ RECEIVE,. BY ;TATE RECEI VC,r} <br /> ISR --- �._ 1 <br /> EH 23 032(REVISED 8101103) <br />