COMPLIANCE INFO_2008 RETROFIT - Laserfiche WebLink

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• 0 SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone: (209)468-3420 Fax: (209)468-3433 YVeh:www sjgov.Or /g ehd FACILITY CONTACT NAME FACILITY NAME - liG'�S tri'C"C /Z SSD FACILITY ADDRESS SITE PHONE#WITH AREA CODE #OF TANKS AT SITE CITY STATE ZIP CODE CA AAPPLICANT CONTACT NAME APPLICANT BILLING NAME APPLICANT MAILING ADDRESS APPLICA PHONE#WITH AREA CODE Z t'uq v *; f- CITYSTATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# -5 C� Cl`Z (✓ —7 Closure Installation Ref' - Retr t Z " U U/ (ACTIVE FACILITY 2003 2004 2005 2006 2007 2008 $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) $550 FEE INCLUDES FACILITY FEE+ 1 TANK(20081 $ $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED $ TANK SURCHARGE=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S24.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place S TANK ID# s CLOSURE FEE=5315/TANK #TANKS X 5315= TEMPORARY CLOSURE Plan Review and Inspections) S TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE=$840/FACILITY REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,7upgrades,s ill buckets,sum s,mist.PIPING REPAIR FEE _$315/FACILITY (use for piping,under-dispenser containme $ MISCELLANEOUS TRANSFER FEE _ $20 $ CONSULTATION FEE = $ 105/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 105/HOUR $ SAMPLING INSPECTION FEE = $ 105/HOUR $ ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY IDI AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 7/18/08)