Laserfiche WebLink
SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone. (209) 468-3420 Fax: (209) 468-3433 Web: www.sj og v.or ehd <br />FACILITY NAME,� <br />TANK ID # (s): <br />FACILITY CONTACT NAME <br />C i� <br />P <br />11 <br />//aa <br />'1l vb <br />2007 <br />11 ADDRESS <br />2009 <br />SITE PHONE # WITFCAREA CODE <br />I %, �,I <br />Db vad to <br />A G - <br />CITY <br />STATE <br />I ZIP CODE <br />I # OF TANKS AT SITE <br />1 lYihy, <br />I CA <br />I q 5 <br />(/ <br />APPLICANT BILLINC2.XAME <br />TANK ID # (s): <br />CLOSURE FEE = $366 / TANK <br />APPLIC <br />T CONTACT NAME <br />2007 <br />2008 <br />2009 <br />2010 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2005-2007) <br />APPLfGANT MAILMAILrNG <br />ADDRESS <br />APPLIChNT <br />PHONE # WITH AREA CODE <br />G ►36 <br />R' I <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2010) <br />$125 PER TANK AFTER FIRST TANK <br />0 <br />4- I -G` 5 <br />CITY <br />I STATE I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Closure <br />Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $366 / TANK <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2005-2007) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 122 / HOUR <br />SAMPLING INSPECTION FEE _ $ 122/ HOUR <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): <br />CLOSURE FEE = $366 / TANK <br />F# TANKS X $366 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $366 / FACILITY <br />INSTALLATION PLAN CHECK <br />TANK ID # <br />PLAN CHECK FEE = $976 / FACILITY <br />E3 <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = V-66-/ F ILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc.) <br />$rig <br />J N <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 httl AKt IiAStU UN I Ht 57ZZ HUUKLT KA 1 t. I IML I NA 1 tAlatUS rtt5 YAIU WILL CSC 13ILLLU I U AYYLIUAN 1. <br />OFFICE USE ONLY <br />SERVICE REQUEST #_t FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07121/10) <br />