Laserfiche WebLink
;Atomyxrr rr , r r +r r + 'r �r ir't.r.��, �•' ', <br /> pr`i0 '�, +"•. t rpt r , r t r.++',+1, �''a..� rh y, rrt+'t a a +r t , r +.p N�,it�wy •,. <br /> SAN JQAQUIN COUNTY �V <br /> ENVIRONMENTAL HEALTH DEPARTMENT V <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fax (2Q9)468-3433 Web:www.sigov.org/ehd t' <br /> FACILITY NAME qFACILITY CONTACT NAMc <br /> Wnkua1 FACILITY ADDRESS <br /> t NE#WI AREA CODE <br /> CIN STATE ZIP CODE #OF TANKS AT SITE <br /> Sfic cA 5 z <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> El lam,a cbf)1-9 -Uv.5, �nc,� t' to r1 (Ol��Tf,' _ <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 25c� vw��,l�at�c�.. 5tcn_�p <br /> CITY "�'�`'r <br /> STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> `= Closure Installation Re air Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2066-2007) 2006 2007 2008 2000 2010 2011 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGF=$15/TANK $ <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 /> TANK ID#(s): CLOSURE FEE=$375/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_$1,000/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID;;(s): <br /> TANK RETROFIT REPAIR FEE _$375/FACILITY (use for monitoring equipment,cold starts,;EVR upgrades,spill buckets,sums misc.PIPING REPAIR FEE_$375/FACILITY use for i in ,under-dis enser containmect. $ <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$125 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# <br /> RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 091,1/11 by KF) <br />