Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />3 , ast Weber Avenue, 3rd Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (5A floor): (209) 468-3433 Web: www.si ov.org/ehd <br />FACILITY NAME FACILITY CONTACT NAME <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />3-1 <br />CITY STATE ZIP CODE # OF TANt <br />w CA �1 Yy t <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />LLC"ti <br />o -l 1 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2003 <br />2004 <br />CITY STATE ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC #. <br />C1 -V '105-e— <br />s -t ( <br />Closure Installation Oipair Retrofit <br />53c) -l -a -Ty -or <br />i AP41\/C CAP11 14 <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID ,# (s): CLOSURE FEE = $279 / TANK �TANKS �$279 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />2000 <br />2001 <br />2002 <br />2003 <br />2004 <br />2005 <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT 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): CLOSURE FEE = $279 / TANK �TANKS �$279 <br />TEMPORARY CLOSURE <br />flan Review and Ins, coons ... <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $279 / FACILITY <br />INSTALLATION <br />(Plan Check and <br />TANK ID # (s) : <br />PLAN CHECK FEE = $7441 FACI <br />REPAIR PLAN CHECK <br />TANK ID # (a): <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILIT( use for monitorin a ui ment, spill buckets, tank sum s, misc. <br />$ <br />PIPING REPAIR FEE = $279 / FACILITY use forpiping. under-d1s enser containment, act. <br />$ <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 />ALL FEES ARE BASED ON'THE $83 HOURLY RATE. TIME THAT EXC"M cFcs DAM Mu 1 ne oil 1 e., �....... . <br />$ <br />OFFICE USE ONLY <br />LIA <br />