Laserfiche WebLink
AQ COUNTY NMW <br /> ENVIRONMENTAL HEALTH DEPARTMENT RECEIVED <br /> E EIVED <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone.(209)468-3420 Fax:(209)468-3433 Web:www.sieov.orz/ehd MAR 16 2015 <br /> FACILITY NAME FACILITY CONTACT NAME IITA It <br /> /�Rstll-ug- 16-t Eru1111V AL <br /> FACILITY ADDRESS SITE PHONEN WITH AREA CODE yT <br /> 2-0/ <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> ST c �7�J CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> NJ�V K-V IfIXA C VNiF�C JUS /r/' <br /> APPLICAN F MAILING ADDRESS APPLICANT PHONE#WITH A EA CODE <br /> �f5 �- /��'Rsi i..✓� �,� �- 3/x_3 <br /> CITY STATE ZIP CODE CLE WORK TO BE DONE CONTRACTOR ICC# <br /> f% L Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) 2008 2009 2010 2011 2012 2015' <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): 390CLOSURE FEE=$ //TANK TANKS X$375& $� <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> s III buckets,sum s,misc. <br /> PIPING REPAIR FEE =$375/FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $125/HOUR $ <br /> SAMPLING INSPECTION FEE = $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$126 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 1/16/2013 by KF) <br /> n <br />