Laserfiche WebLink
Vu [�LCJ71 17t: 41 LC74bty4yy t- It- IH t-LUUe h'L:li IJa <br />SAN JOAQU'N ^OUNTr P(JELIG HEALTH SERVICES-ENVIRONNIF"TAL HEALTH DIVISIO(d <br />UNDERC 'JND STORAGE TANK PROGRAM I JVORKSHEET <br />FACILITYNAME <br />FACILITY CONTACT <br />r <br />w' <br />41 �/Y an <br />-J <br />MICHAEL SPENCE <br />FACILITY ADDRESS <br />SITE PHONE tt VviTij AREA CODE <br />6649 EMBARCADERO DRIVE <br />(209 951-1551 <br />CITY STATE <br />ZIP CODE # OF TANK <br />ZIP CODE <br />CIRCLE WORK TO BE DOME: <br />Closure InebuaLbn:Pair etmM <br />STOCKTON CA <br />95219 2 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAM <br />// <br />r) <br />41 �/Y an <br />�4�� YCG�lIn <br />APPLICANT MA&ING ADDR S3 I <br />APPLICANT PHONE N WITH AREA CODE <br />01 Bc K <br />z 7 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DOME: <br />Closure InebuaLbn:Pair etmM <br />C '-e- S C �7 <br />y- 30 % <br />At;I IV r- FAUILIIT <br />TANK 10 # s CLOSURE FEE = $281 / TANK <br />I V TANKS X $2$1 = <br />1995-1999 <br />2000 <br />2001 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($170)x(#ta�k3)x(#ofyenmapFiicable) <br />CONSULTATION FEE = $ 87/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />UNAUTHORIZED RELEASE EVALUATION FEE - S 87 /HOUR <br />SAMPLING INSPECTION FEE = S 871 HOUR <br />$ <br />TANK PENALTY ASSESSES <br />$ <br />TANK SURCHARGE - $8 / TANK <br />STA.'S SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $101 FACILITY <br />PERMANENT CLOSURE <br />Removal cr Permitted Clusure in Place) <br />TANK 10 # s CLOSURE FEE = $281 / TANK <br />I V TANKS X $2$1 = <br />TEMPORARY CLOSURE <br />(Plan Review and Ins ecbcrs) <br />TANK ID #(s) . <br />TEMPORARY CLOSURE FEE = S261 /FACILITY <br />U-LATION PLAN CHECK <br />Chec' and Construction Ir <br />LTANK IC #(s) I PLAN CHECK F=E = 5696 / FACILITY I s <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE = S 20 <br />$ <br />CONSULTATION FEE = $ 87/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE - S 87 /HOUR <br />SAMPLING INSPECTION FEE = S 871 HOUR <br />$ <br />OFMCL USE ONLY <br />SERVICE REQUEST AGILITY ID 1 AMOUNT RECEIVED CHECK $0 RECEIVED BY I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 2.8-011 <br />