Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />304 ast Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 1468-3420 Fax (S"' floor): (209) 468-3433 Web: www.sj o, v.org/ehd <br />I <br />FACILITY NAME I <br />FACILITY CONTACT NAME <br />co (-�6P 6-2-0 <br />6i�lln =.4;1 a -L l 0. 0-0-� I -2._-- <br />FACILITY ADDRESS <br />SITE PHONE!# WITH AREA CODE <br />3Li 2S 'r ate; lv� <br />2 `835- ►(�� <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />�r C' i. <br />CA <br />CA <br />SZk O <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />k\ U �( <br />6i�lln =.4;1 a -L l 0. 0-0-� I -2._-- <br />APPLICANT MAILING ADDRESS ( <br />APPLICANT PHONE # WITH AREA CODE <br />LP1-1 z L -ac_. o <br />b s - 1-u1. to <br />CITY <br />(STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />b3/ HOUR <br />CA <br />SZk O <br />Closure Installation Repa' Retrofit <br />Lt 3 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $2791 TANK <br />T # TANKS X $279 = <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$500 FEE INCLUDES FACILITY FEE + I TANK2000 <br />$ <br />SAMPLING INSPECTION FEE _ $ <br />b3/ HOUR <br />$ <br />ALL FEES ARE BASED ON THE $93 HOURLY <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID <br />SR <br />FN 94 (147 /DC1/IcEn ff4l4w— <br />$125 PER TANK AFTER FIRST TANK <br />AMOUNT RECEIVED CHECK # RECEIVED BY <br />DATE RECEiIVED <br />gl <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIESINOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $2791 TANK <br />T # TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $279 / FACILITY <br />N PLAN CHEC <br />id Construction <br />TANK ID # <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK - '— <br />TANK ID # (s): <br />TANK RETROF=IT REPAIR FEE = $279 / FACILITY (use for monitoring equipment spill buckets tank sumps misc.) <br />$ <br />'? <br />2 <br />$d <br />PIPING REPAIR FEE =$ 9 / FACILITY (use for piping,under-dispenser containment ect) <br />8S• <br />IYI IJI✓C LLAN CV Ua - <br />TRANSFER FEE _ $ 20 <br />Q� <br />$ <br />CONSULTATION FEE _ $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 931 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ <br />b3/ HOUR <br />$ <br />ALL FEES ARE BASED ON THE $93 HOURLY <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID <br />SR <br />FN 94 (147 /DC1/IcEn ff4l4w— <br />RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />j <br />AMOUNT RECEIVED CHECK # RECEIVED BY <br />DATE RECEiIVED <br />