Laserfiche WebLink
OFFICE USE ONLY <br />SERVICE REQUEST # F <br />SR <br />EH 23 032 (REVISED 01/29/07) <br />LITY ID AMOUNT RECEIVED CHECK # <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL <br />HEALTH DEPARTME✓ <br />304 East Weber Avenue, 3`d Floor, Stockton, CA 95202-2708 <br />Telephone: (209) 468-3420 Fax (S"' floor): (209) 468-3433 Web: www.sjgov.orQ/ehd <br />FACILITY NAME <br />Csz�'(��� <br />FACILITY CONTACT NAME <br />A' <br />FACILITY ADDRESS <br />mac Co <br />l(<<^ <br />SITE PHONE #WITH AREA CODE <br />CITY <br />1/ 2 � S' 7tr3 <br />STATE <br />Z P CODE <br /># OF TANKS AT SITE <br />5`�ct`'1 ` <br />CA <br />els 2� <br />/ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />4/7%ce ►., <br />APPLICAIQT MAILING ADDRESS <br />jc <br />APPLICANT PHONE # WITH AREA CODE <br />z='( :Y'S--;`q(�- <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC <br />Closure Installatio epajr;Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />2002 <br />2003 <br />2004 2005 2006 2007 <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <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): <br />TEMPORARY CLOSURE <br />CLOSURE FEE = $285 / TANK <br /># TANK�X$285 = <br />$ <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $285 / FACILITY <br />$ <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />$ <br />PLAN CHECK FEE = $760 / FACILITY <br />OFFICE USE ONLY <br />SERVICE REQUEST # F <br />SR <br />EH 23 032 (REVISED 01/29/07) <br />LITY ID AMOUNT RECEIVED CHECK # <br />