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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENS <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> T&-phone. (209)468-3420 Fax. (209)468-3433 Web:www.sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> San Joaquin General Hospital JamesKari <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 500 W. Hospital Rod 1 209 ) 468-6166 <br /> CITY ISTATE ZIP CODE #OF TANKS AT SITE -------- <br /> French Camp CA 95231 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Bagley Enterprises, Inc. JessecBerumen <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#NTH AREA CODE <br /> 2370 Maggio Circle, #4 209) 367-4800 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CON 'TOR[CC# <br /> Lodi CA 95240 closure Installation(Repair Retr°fit 8014628 <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+I TANK(2008) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$315 1 TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE $315 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE $840 d FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,suM,misc.) <br /> PIPING REPAIR FEE $315/FACILITY (use for piping,under-dispenser containment,ea.) $315.00 <br /> MISCELLANEOUS <br /> TRANSFER FEE $20 <br /> CONSULTATION FEE $105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR <br /> SAMPLING INSPECTION FEE = $1051 HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID VALL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> ISERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHBCKX I RECEIVED BY--_j DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED 7M81" <br />