Laserfiche WebLink
SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor,Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5"floor):(209)468-3433 Web:www.sigov•or_I7/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Cr-f-* s(:I- T fbQs aKTJ%IQa <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 036 UAV 57t&'� r ZO q 01 1 �2 2- <br /> CITY <br /> CITY LSTATE ZIP <br /> CODE #OF TANKS AT SITE <br /> e3 1-tuL* CA I J— <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR lCC# <br /> Closure installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=S15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00!FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Pace "� <br /> TANK ID# s :TA 0✓4 -716()_7 CLOSURE FEE=$2791 TANK #TANKS X$279= $2-77 <br /> TEMPORARY CLOSURE <br /> Plan Review and inspections) $ <br /> TANK ID#(s): TEMPORARY CLCISURE FEE_$279!FACILITY <br /> INSTALLATION PLAN CHECK <br /> Pian Check and Construction Ins actions $ <br /> PLAN CHECK FEE_$744 1 FACILITY <br /> TANK ID#(s): <br /> REPAIR PLAN CHECK <br /> TANK ID# s l <br /> TANK RETROFIT REPAIR FEE _$279 1 FACILITY (use for monitoring equipment,spill buckets,tank sumps,mist.) S <br /> PIPING REPAIR FEE $279 1 FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE = S20 $ <br /> CONSULTATION FEE = 5 93!HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $931 HOUR $ <br /> SAMPLING INSPECTION FEE = $931 HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE REGEIVED <br /> SR <br /> EH 23 032(REVISED 92!22!05) <br />