Laserfiche WebLink
• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEN <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.or <br /> FACILITY NAME FACILITY CONTACT NAME <br /> , tsGR Prz (2,M A) NTa G. FE1OcK <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> '7-1'7 w. ofaM A[. 264 (6 4309 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> t4t-i-mr- CA CA F-5,31 .�-- <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> S'uT',t Su PF-Al o Iti DIST— S SRV I C E 014A/ S"-'7-)m/-OV <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> P--o- 136)c 1119-7 qts' 5719 - -7887 <br /> CITY STATTE. ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> S/� Rp ON C f", Cr 4 S'93 osure Installation Repair Retrofit �Z 5'��js? • (� <br /> ACTIVE FACILITY <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2010) $ <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 CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place // <br /> TANK ID#(s): I I CLOSURE FEE=$366/TANK #TANKS X$366 <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$366/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$976/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE _ $122/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $122/HOUR <br /> SAMPLING INSPECTION FEE _ $122/HOUR <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/21/10) <br />