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• SAN JOAQUIN COUNTY. • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fac.(209)468-3433 Ff'eti:www.sicehd.com <br /> UWACILMUM—E 'FACILITY CONTACT NAME <br /> 517E PHONE#WITH AREA CODE MAR ! 6 5 <br /> SM <br /> I STATE ZIP CODE 1 #0 TAL <br /> CA C{ Z' f1r_p,�l�ncoe icer• <br /> APPLICANT BILLING.NAME - APPLICANT.CONTACT NAME <br /> �Ll\F.T�1- CJ�MTK'AC70B� k <br /> APPLICANT MAILING ADDRESS. APPLICANT PHONE#WITH AREA CODE <br /> 2536 is.)u�tuPcai qt;� _ <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure InstatIatlon Re air Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) 2007 2008 2009 2010 2011 2012 <br /> $550 FEE INCLUDES FACILITY FEE+.I TANK(2009-2012) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> .TANK PENALTY ASSESSED $ <br /> $ <br /> TANTS.S.UROHARGE_=$15.1.TANK_-..--- __ .___ .._...___ . ... . <br /> $ <br /> STATE.SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00!FACILITY <br /> PERMANENT.CLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK-ID#.s ;. . _.__.. CLOSURE FEE=.$3761 TANK #TANKSX. 37S- <br /> TEMPORARYCLOSURE <br /> TANK.ID#(s): TEMPORARY CLOSURE FEE= 3751 FACILITY <br /> INSTALLATION PLAN.C,HECK . <br /> -Plan Check and Construc5on Inspections) <br /> ITANKIO'#(s) _ : I PLAN CHECK FEE=.$10001 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ `��O✓ <br /> 7- YANK-RETROFIT REPAIR FEE _$3751,FACILITY-(use for-mobitorin f <br /> g equlpmen4 cold starts,EVR upgrades, <br /> .. __.. �.__._..... _ ___ . ..._ ...___....__._....... -s III-buckets;sums-mise. ... . <br /> PIPING REPAIR FEE _$3751 FACILITY use for pipIng,under-dls enser containment,ect. <br /> 'MISCELLANEOUS <br /> --TRANSFER.FEE ._=.$..25 $ <br /> CONSULTATION FEE _ $1251 HOUR <br /> "UNAUTHORIZED RELEASE EVALUATION FEE = S 1251 HOUR <br /> -SAMPLING.1NSPECTION.FEE . g $,1251:HOUR. $ <br /> -" -AI-LFEES"ARE BASED-ON"THE"$173 HOURLY RATE:TIMETHATEXCEEDS'FEES PAID WILUSE'BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> I-RECEIVED-SY- <br /> EN <br /> _ <br /> 23032/REVISED 04113112b KF1 - <br />