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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.s'gov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Wtf4C C0oN-)VI STAy�tO�D -2A-m%e1w S/m4)-1 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1111 E <br /> CITY 1 STATE ZIP CODE I #OF TANKS AT SITE <br /> LOJ71 CA 9S2- 40 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> WINE CMUI-AV� S h4( 0w-1 <br /> -APPLICANT MAILINGff'^__,�.IAD�DRESS APPLICANT PHONE#WITH <br /> 1AREA CODE <br /> 1 11 r" Y-c rl ll` ► L11r � L{W ) O d0 "_ '7 1 _\% <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Q$-2Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> $ <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 /> $ <br /> TANK ID#(a): CLOSURE FEE=$3451 TANK #TANKS X$345= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$345/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$920/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, '345, OO <br /> s ill buckets,sum s,misc. <br /> $ <br /> PIPING REPAIR FEE _$345/FACILITY use for piping,under-dispenser containment,set. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE = $115/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $115/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $115/HOUR <br /> ALL FEES ARE BASED ON THE 5115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID j AMOUNT RECEIVED I CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07101/09) <br />