Laserfiche WebLink
' • SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> TR-PM)S poa 2Zv2 ODu C <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 0 S33 £. I-�r�aSsv wry 4Yo7-(o(0 y( <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> $2c1�a 1 CA 'q5 Ze)S' I 'S1sv£ry 61 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> C3a-c+e..�d sN��awrs�S, y,.z, '3�s�a>♦ (3ac-��y <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> `Z3 -76 MAGcs� csruQ, `�� 7&j 36-7- "aD <br /> CITY ISTATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> L-O D Z oi52 4p Closure Installation Repair etrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) 2004 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$345/TANK #TANKSX$345= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANKID#(s): TEMPORARY CLOSURE FE -$345 ACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$9201 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEF/=$345/PACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc.) �'� <br /> $ <br /> PIPING REPAIR FEE -E34 /FACILITY use for piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $115/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $115/HOUR <br /> SAMPLING INSPECTION FEE _ $115/HOUR <br /> ALL FEES ARE BASED ON THE$116 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 I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/01/09) <br />