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) 469-3433 ff,'eb: www.sigov.ore/ehd <br />FACILITY NAME _ FACILITY CONTACT NAME <br />She CONTACT <br />-SS <br />FACILITY ADDRESS SITE P ONE # WITH AREA CODE <br />- - -CI 4615 Gt-� fX'f -- - - -- <br />CITY STATE ZIP CODE �� T � � fi� <br /># OF TANKS AT SITE <br />��vCk td►� CA g52I S <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />APPLICANT MAILING MAILING ADDRESS APPLICANT PHONE # WITH AREA COD E <br />535 IN Yom Tr. 1 j Otol - 3"7 <br />CITY STATE ZIP CODE . CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />*C t�1-� GSI— �52UGj Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) 2004 .2005 2006 2007 2008 2009 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (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 =$24.00/ FACILITY $ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : CLOSURE FEE= $315 /TANK # TANKS X $315 = $ <br />TEMPORARY CLOSURE <br />Plan Review and' <br />TANK ID # (s) : TEMPORARY CLOSURE FEE _ $315 / FACILITY $ <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Ins ections <br />TANK ID # (s) : PLAN .CHECK FFA _ $840 / FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) <br />_ / (use for monitoring equipment, cold starts, EVR upgrades, $ <br />_ - - TATIK. REfROF1T REPAIR FEE $315 FACILITY _ sill. buckets, sumps, misc.): . <br />34S. <br />PIPING REPAIR FEE _ $315 7 FACILITY$ <br />(use for pipin , under-dispenser containment, ect. <br />MISCELLANEOUS <br />'TRANSFER FEE _ $ 20 $ <br />CONSULTATION FEE _ $ 105/ HOUR $ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 105 / HOUR $ <br />SAMPLING INSPECTION FEE _ .11051 HOUR $ <br />ALL FEES ARE BASED ON THE $105 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />0FFICE USE ONLY <br />