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' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton.CA 95202-3029 <br /> Telephone: (209)468-3420 Fax:(209)468-3433 Web:www.sj ov.or /�ehd <br /> FACILITY NAME/ /y, /FACILITY CONTACT NAME i <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> r2-/-� v (All 43 f '11 C-"0 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> leo/ CA q,S�`U ;3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> y., 5 Closure Installation Repai -3-07 <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008-2009) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s : CLOSURE FEE=$345/TANK #TANKS X$345= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$345!FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(s): PLAN CHECK FEE_$920/FACILITY $ <br /> REPAIR PLAN CHECK fi' ,S �. j� 3 Aa J <br /> TANK ID#(s): jy. At <br /> - <br /> TANK <br /> RETROFIT REPAIR FEE _$345/FACILITY (use for monitoring equipment,cold starts, EVR upgrades, $ <br /> spill buckets,sumps, misc. <br /> PIPING REPAIR FEE _$345/ FACILITY (use for piping.under-dispenser containment,ecl.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $ 115/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 115/HOUR $ <br /> SAMPLING INSPECTION FEE = $ 115/HOUR $ <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07101109) <br />