Laserfiche WebLink
-1) irJJi 10t: 41 LC'74b7:14» F'il' IN r'LULt" r,"I 1]y <br />• SAN JOAQ17'N COUNTt PUBLIG HEALTH SER`/ICE3-ENVIR0Nr1E:vTAL HEALTH Divisi0i,) <br />UNDERGf 1ND STORAGE TANK PROGRAM FI 1VORKSHEET <br />FACILITY <br />FACILITY CONTACT <br />MMNAME <br />7r1a1-I <br />MICHAEL SPENCE <br />FACILITY ADDRESSWITH <br />AREA CODE <br />6649 EMBARCADERO DRIVE <br />(209 951-1551 <br />CITY STAT E <br />ZIP CODE # OF TANK I <br />STOCKTON CA <br />95219 2 <br />APPLICANT BILLINGNAME <br />APPLICANT CONTACT NAL1E <br />/ r� �e <br />T t' <br />G �V/3? �ih <br />�R�� 1C o/l <br />APPLICANT M ING ADDRESS I <br />APPLICANT PHONE N WITH AREA CODE <br />i, V 1 3o `, <br />Z 76 <br />(mood -5-3 /)- 93 96-� <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO 9E DONE: <br />Closure <br />C '-,f C q <br />Ar-TrIVE FACILITY <br />TAAIK IC # s CLOSURE FEE = S281 I TANK <br />xf TANKS X 52$1 = <br />1996 - 1999 <br />2000 <br />2001 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />(5170) X (0 tanks) X (# of yearn applicable) <br />CONSULTATION FEE = $ 87/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />UNAUTHORIZED RcLEASE EVALUATION FEE $ 87 /HOUR <br />_ <br />I <br />SAMPLING INSPECTION FEE = $ 871 HOUR <br />� <br />TANK PENALTY ASSESSED <br />+ <br />I I <br />TANK SURCHARGE _ $8 /TANK <br />� <br />STA."E SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM = S101 FACILITY <br />PERMANENT CLOSURE <br />Removal cr Permitted Closure in Place) <br />TAAIK IC # s CLOSURE FEE = S281 I TANK <br />xf TANKS X 52$1 = <br />TEMPORARY CLOSURE <br />(Plan Review and :ns edor.3) <br />TRANSFER FEE = $20 <br />TEMPORARY CLOSURE FEE = S261 /FACILITY <br />LANK IC #(s) ____ I PLAN CHECK FEE = $5961 FACILITY S <br />MLSCELLANEOUS <br />$ <br />TRANSFER FEE = $20 <br />$ <br />CONSULTATION FEE = $ 87/ HOUR <br />$ <br />UNAUTHORIZED RcLEASE EVALUATION FEE $ 87 /HOUR <br />_ <br />� <br />SAMPLING INSPECTION FEE = $ 871 HOUR <br />—... . ------ v racu rnw T11" Cm 0166GV 11.^rr61VHf4 I. <br />OFFICE USE ONLY <br />SERVICE REQUEST is 1 FACILITYID AMOUNT RECEIVED CHECK # RECEIVE= BY I DATE RECEIVED <br />SR <br />EH 72 M2 IRFVISED 2-6-0 11 <br />