Laserfiche WebLink
11/10/2010 07:16 5307499892 MIDVALLEY CONSULTING PAGE 11 <br /> SAN JOAQM COUNTY <br /> ENVIRONMENTAL IIEALTII DGPARTM BNT <br /> 600 East Main Slrcet,Stockton,CA 95202-3029 <br /> Te►epkone:(209)468-3420 F=(209)468-3433 Web:www-A 92X.agL <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS <br /> ` t)TUVL SITE PHONE#W11111 AREA CODE <br /> n 2I. CL ZIP CODE #0 TANKS AT SITE <br /> CITY <br /> CA <br /> APPLICANT RIWNO NAME APPLICANTCONTACT NAME <br /> lI <br /> AppLICANT LI ADDRESS APPLICANT PHONE#WR AREA CODE <br /> ` STATE 23P CODE $GRCLE WORK TO BE..N I CONTRACTOR ICC# <br /> CITY r� t, <br /> s <br /> C� ( Closure Installation Repair Retroffi �6Ls Ly <br /> ACTIVE FACILITY <br /> aaos zoos zoo? 2008 Zoos 2010 <br /> $%0 FEE INCLUDES FACILITY FEE+1 TANK 120135-2007) <br /> $55o FEE INCLUDES FACILITY FEE+1 TANK(2908-2010) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15 1 TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.001 FACkITV <br /> PERMANENT CLOSURE <br /> Removal or PemMted Closure in Place <br /> TANK ID# s CLOSURE FEE=53661 l...K7 #TAWS X$366 a <br /> $ <br /> TEMPORARY CLOSURE <br /> (Flag Review and In 'ors <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$3681 FACILRY <br /> INSTALLATKN4 PLAN CHECK <br /> Plan Check end CorlsWeSon I actions <br /> TANK ID i(s): PLAN CHECK FEE_$976/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> a <br /> TANK RETROFIT REPAIR FEE =$3661 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill btdf is sum miser <br /> a <br /> PIPING REPAIR FEE _$3881 FACILITY use for oping,under-dispanser cordalnment ecl. <br /> MISGELLAgE0U8 <br /> $ <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE _ $1221 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $1221 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE - 122/HOUR <br /> ALL FEES ARE BASED ON THE$722 HOURLY RATE- TIME THAT EXCEEDS FEES PAID WILL BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUESTF FACILTIY ID AMOUNT RECEIVED CHECKi I MCEIVEDBY DATE REf.'EIVED <br /> 5R <br /> EH 23 032(REVISED 0721110) <br />