Laserfiche WebLink
SAIF RAQUIN COUNTY <br /> ENVI R,)NMENT,',L HEALTH DEPARTMENT <br /> 600 East Aain Stre:t,Stockton,CA 95202-3029 <br /> Telephone: (209)468- ;420 Tur:(209)468-3433 Web:www.sj ov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> tic <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> `y L— l-- _ �-- <br /> CITY A i E ZIP CODE #OF TANKS AT SITE <br /> APPLICANT #G NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> � ) isc,-'e- SG c6 OG <br /> CITY STATE "F _ J. E CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 57­Z.G ,�-� _ Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2004 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK �-L0� 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TAP: <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT JENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): OSURE FEE=$315/TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): 1 '.1PORARY CLOSURE FEE=$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) _ <br /> TANK ID#(s): PLAN CHECK FEE_$840/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$315/FAC ruse r monitoring equipment,cold starts,EVR upgrades, $ <br /> spo ,ickets,sumps,misc. <br /> PIPING REPAIR FEE =$315/FACILITY ruse )r piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $ 105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FE_ HOUR $ <br /> SAMPLING INSPECTION FEE = S 105/H( $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE Tib; E.,.CEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID '0 )r <br /> r RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/23109) <br />