Laserfiche WebLink
SAN JOAQUIN qqJTY PUBLIC HEALTH SERVICES-ENVIRON"--NTAL HEALTH DIVISION <br /> UNDERGRMND STORAGE TANK PROGRAM, .EE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Tony J <br /> FACILITY ADDRESS SI PH NE A CODE <br /> 767 N. Alpine Rd. 209) 948-2482 <br /> CITYSTATE ZIP CODE #OF TANKS AT SITE <br /> Stockton, CA 95215 1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Tony Jockovich Trust Imarie Lopez, Trustee <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 9XNKRXXnXXXX93X1X 8567 Orford Rd. 209 948-2482 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> X <br /> CA 9-9215 --Closure Installation Repair Retrofit <br /> ACTIVE FACILITY - <br /> 1996- 1999 2000 2001 Z**L Ion <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK ($170)X N tanks)X(#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK ( �Q SUdg0 SOO <br /> TANK PENALTY ASSESSED d I f7A /.]O SDO $roc .Sao <br /> TANK SURCHARGE=$8/TANK <br /> $ 8.00 <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S101 FACILITY <br /> (f0 <br /> PERMANENT CLOSURE Removal <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s CLOSURE FEE=5261 /TANK #TANKS X = 2 •00 <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) $ <br /> TANK ID#(s): TTT <br /> TEMPORARY CLOSURE FEE_$261 /FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections $ <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY <br /> REPAIR PLAN CHECK <br /> L•Ogrc!! <br /> TANK ID#(s): <br /> $ <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = 4% <br /> $ �J <br /> TANK RETROFIT REPAIR FEE =$2611 FACILITY $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = S 871 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $87/HOUR $ <br /> SAMPLING INSPECTION FEE _ $871 HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK j RECEIVED BY I DATE RECEIVED <br /> SR <br />