Laserfiche WebLink
SAN JOA QUIN COUNTY ENVIRONMENTAL HEALTH I--4RTMENT <br />UNDERGRC ID STORAGE TANK PROGRAM F - _ WORKSHEET <br />FACILITY NAME FACILITY CONTACT NAME <br />v Q f e We AZ a i /V G,---- �' <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />6 G 4- ? rvt 6L 1p v- �o q 76'/ - / <br />CITY _ STATE I ZIP CODE # OF TANKS AT SITE <br />5-�� c/c 7 SCA g.�-J q %�cvo�� , <br />APPLICANT BILLING NAME <br />1998 <br />I APPLICANT CONTACT NAME <br />GI, ! T!_= Ta2-- <br />_ <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />CITY— STATE <br />I <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair et•c''?t �f <br />-5-,1- 0 r 7 <br />NSIALLAIIVN PLAN (;HtGK <br />,Plan Check and Cc !Ion Inspections) <br />i ANP Q i; (s) <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />7-- <br />MISCELLANEOUS <br />1998 <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170) X (#tanks) <br />($170) X (#tanks) <br />$'i25 PER TANK AFTER FIRST TANK <br />F�:.: VAI_/ 'ASSESSED <br />i <br />'".11K SUR--mARGE =::,15 / TANK <br />$ <br />i <br />-- - - -- -- -- <br />-- -- — - — -----_..)-_ <br />I` ST4TE SURCHARGE FOR FACILITIES r4;DT,ALREADY ON INVENTORY IN.-. CUPA PROGRAN', =$24.00i 1-A,:ILITY - <br />1 <br />PERMA!? ' 4T CL S- URRE <br />_ <br />;a•�:iv ; „ .'eer„i;t�u s,:ivsjia in Place' <br />I TANK W #(S) _—_.. ._._..—._ <br />,LO.`.,JRE. 3%'9 i •TANK. 1 # TAP;.'-< Y :279 <br />TF!APCJ Y #X ",'AE <br />(F'tan Revie-. and Ins ctlons) <br />NK It; # <br />TEMPORtiRY (,;_`):-URE <br />FEE = $279 / FACILI 1-y' <br />NSIALLAIIVN PLAN (;HtGK <br />,Plan Check and Cc !Ion Inspections) <br />i ANP Q i; (s) <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />7-- <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$ <br />• •-- • --_ • •• •_ �• •----- --•• ...� .�•� ..�+.�,.� . ...-., �. ..,..� ...r.. Lnaiccv.� rccJ rM1u I�ILL OC �ILLCII 1 V Nrr Lll.Nni 1 . <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EHD 23-02-001 <br />REVISED 11/24/03 <br />