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■ l E *;mea.u. b tiL rvm V <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT JUN 0 7 2017 <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax,(209)468-3433 Web:w .S'cehd. 1':=_N IT/!1 <br /> VIR0N�, HEALTH <br /> FACILITY NAME FACILITY CONTACT NAME - --- !T <br /> Jahant Food & Fuel Mr. Singh <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 2432 N Highway 99 209 327-2863 <br /> CITYSTATE ZIP CODE #OF TANKS AT SITE <br /> Acam o CA 95220 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Megan Mitchell <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr 209 461-6337 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE-SfCONTRACTOR ICC# <br /> OC On Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2010 2011 2012 2013 2014 2015 <br /> $130 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$390/TANK #TANKS X$390= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$390/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1040/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$390/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 625.50 <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE=$390/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 A$$CONSULTATION FEE = $130/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1301 HOUR SAMPLING INSPECTION FEE = $130/HOUR <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE 1 $625.501 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED CHECK# I RECEIVED BY I DATE RECEIVED <br /> EH 23 D32(REVISED 04-22-15) <br />