Laserfiche WebLink
(, SAN JOAQUI N COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT . <br /> 600 East Main Street;Stockton,CA 95202-3029 <br /> j Telephorse:(209)468-3420 Far:(209)468-3433 Web:MM-s' Ov.or ehd <br /> FACI AIME <br /> .FACILITY CONTACT NAME <br /> FACILJTYADDRESS �� <br /> SfiE PHONE 0 WITH AREA CODE <br /> C I ATE ZIP CODE J /a #OF TANKS AT SITE <br /> CA 9�z�o <br /> APPLICANT BILLING NAME APPLI T CONTACT.NAME <br /> APP CANT MAILING ADD SS <br /> APPLICANT PHO #WITWAREA CODE <br /> CISTATE , ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> � " -- Closure Instatla0on air Retofit. � <br /> t <br /> ACTIVE FACILny - <br /> $500 FEE INCLUDES FACILFrY FEE+T TANK(20052007) 2005 2006 2007 2008 2009 2010,. <br /> S54FEEJNCLUDESF9ra rry ter= ra"ANK: 00&20702 <br /> . . . <br /> 5115 PEfi�'ANK AFTER FIR5T TANIR-.—.._. <br /> TA NK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal w Permitted Closure in Place <br /> ':=TANK-IO#'s CLOSURE FEE=$366/TANK #TANKSX5366= $ <br /> TEMPO CLOSURE "- <br /> P Review and I ns - - . <br /> -TANK ID#(s): <br /> TEMPORARYCLOSURE FEE_$366/FACILITY <br /> INSTALLATION PLAN CHECK <br /> . .Plan Check and Construc0on <br /> . = 67FA-CII <br /> REPAIR PLAN CHECK - - <br /> TANKID#(s): <br /> 4NNK RFMOFIT REL?AIR:EEE=066JFAGILITj'luse:for'monitoon - <br /> V~ •---- —R-e9uipmentrCC0WS1Rff%EV -0R9ra'Kes. --. .. <br /> . III'budcets,sum s,lresC. <br /> -PIPINGREPAm FEE_$36 6/FACILITY use for piping,u-ndsrvdIspeAser containment,ecL . .'... . <br /> ' TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE- = $122/HOUR - $ <br /> .UNAUTHORIZED RELEASE EVALUATIO., r- <br /> SAMPLING INSPECTION FEE _ $122/HOUR - $ <br /> ALL FEES ARE BASED ON THE 5722 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE:USE.ONLY <br /> SERVICE REgUEST# FACILffY a)' _ AMOUNT-RECEIVED -CHECK# .RECEIVED BY DATE RECEIVED <br /> SR I <br /> ' EH 23 a32(REVISED 0721Na): - - I � ' <br />