COMPLIANCE INFO_2003-2011 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sj ov.or /g ehd OFACIL�ITYAD FACILITY CONTACT NAME ESS SITE PHONE#WITH AREA CODE STATE ZIP CODE #OF TANKS AT SITE _FCA APPLICANT BILLING NAME APPLICANT CONTACT NAME `1 f APPLICANT MAILING ADDRESS I APPLICANT PHONE#WITH AREA CODE CITY 5_4 —STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# fi6MjWClosure Installation Repair Retrofit ACTIVE FACILITY $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 2006 2007 2008 $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID# s CLOSURE FEE_$315/TANK #TANKS X$315= $ TEMP_ORARY CLOSURE Plan Review and Inspection,) - TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY $ INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE_$840/FACILITY $ REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE _$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ --ill buckets,sumps,misc. PIPING REPAIR FEE _$315/FACILITY (use for i in ,under-dis enser containment,ect.) $ MISCELLANEOUS TRANSFER FEE _ $20 $ CONSULTATION FEE _ $105/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR $ SAMPLING INSPECTION FEE _ $105/HOUR $ ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SIR EH 23 032(REVISED 7/18/08)