Laserfiche WebLink
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 14'eb:www.siaov.orE/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 4 FtW plc+ wv- -frit�ov� <br /> FACILITY ADDRE S SITE PHONE#WITH AREA CODE <br /> (Q(+4S N - (..t)M ) �f'l�- �f 0q- <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> Stbift4o,n ICA '1 1 -3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> StvU'Cts o,t a e�VL, - tee. EdcLlr LL h * <br /> APPLICANT MAILING ADDR SS APPLICANT HONE#WITH AREA CODE <br /> 6-30 QO1 K lA Ault- li a437 �03 S. . . <br /> CITY - STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC If <br /> Se'o— '( Closure Installation Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE + 1 TANK(2002-2007) 2003 2004 2005 2006 1 2007 2008 <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008) <br /> $125 PER TANK AFTER FIRSTTANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24:001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections). <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$294/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 3 s <br /> s ill buckets,sum s,mise. <br /> PIPING REPAIR FEE _$294/FACILITY $ <br /> (use for piping,under-dispenser containment,act.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE _ $98l HOUR $ <br /> ALL FEES ARE BASED ON THE S9e HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> rSERVICE REQUEST FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12131/07) <br />