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'%WV %%.4 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:Ww .sieov.ore/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Chevon #98264 Debbie <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3775 Tracy Blvd. 209-836-9422 <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> Tracy CA 95376 L 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Able Maintenance, Inc. Eric Janzen <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 3224 Regional Parkway 707 293-2986 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Santa Rosa CA 95403 Closure Installation Repair Retrofit 5252033 <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(2006-2009) <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=$49.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(a): CLOSURE FEE=$345/TANK #TANKS X$345= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$345/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(a): PLAN CHECK FEE_$920/FACILITY is <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> —spill buckets,sumps,mist. <br /> PIPING REPAIR FEE _$345/FACILITY use for piping,under-dispenser containment,act. $375.00 <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $ 115/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $115/HOUR $ <br /> SAMPLING INSPECTION FEE _ $ 115/HOUR $375.00 <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECENED BV DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/01/09) <br />