COMPLIANCE INFO_1995-2004 - Laserfiche WebLink

Home Browse Search

SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT UNDERGROOP STORAGE TANK PROGRAM F*WORKSHEET FACILITY NAME FACILITY CONTACT NAME �6u•v7�G7 G c.�8 !"cZL Z-4- FACILITY -LFACILITY ADDRESS SITE PHONE#WITH AREA CODE CITY STATE ZIP CODE #OF TANKS AT SITE �7 o c.�T� CA 5;�5 z o 5 APPLICANT BILLING NAME APPLICANT CONTACT NAME ��ZL CJiL /f a�tcc �G< c�Zc�^o.v.`' APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE yv // F<�.�/Z S CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: C.4 Z Closure nstallation Repair Retrofit ACTIVE FACILITY 1999 2000 2001 2002 2003 2004 $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x(#tanks) $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ P ENT CLOSURE _fRemova or Permitted Clos re in lace j G 1'.74,01 $ 7 00 TANK ID#(s): 4¢ -y 2 -1 CLOSURE FEE=$279/TANK #TANKS X$279= J TEMPORARY CLOSURE Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $ REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,misc.) PIPING REPAIR FEE _$279/FACILITY (use for piping, under-dispenser containment,ect.) MISCELLANEOUS TRANSFER FEE _ $20 $ CONSULTATION FEE = $93/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR $ SAMPLING INSPECTION FEE = $93/HOUR $ ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY T DATE RECEIVED SR I T EH 23 032(REVISED 01/22/04)