COMPLIANCE INFO_2013-2015 - Laserfiche WebLink

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SAN JOAQUIN COUNTY 0 ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sjgoy.org/ehd FACILITY NAME FACILITY CONTACT NAME APPLICANT CONTACT NAME 6;,j FACILITY ADDRESS SITE PHONE # WITH AREA CODE 2- v , L4, 9 2 -/-- CITYI STATE ZIP CODE # OF TANKS AT SITE S CA �y ' i S 10 1 e s ill APPLICANT BILLING NAME TANK ID # (s): APPLICANT CONTACT NAME 6;,j 2009 2010 APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2-k-4 —%1— Al c C CITY I STATE I ZIP CODE CIRCLE WORK TO BE DONE CO TRACTOR ICC # $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) Closure Installation Retrofit i.�= ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $375 / TANK 2008 2009 2010 2011 2012 2013 $ $500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) $ PIPING REPAIR FEE = $3751 FACILITY use for piping, under -dispenser containment, ect.) $550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) $ $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $375 / TANK # TANKS X $375 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $375 / FACILITY X4I:1 Check and TANK ID # PLAN CHECK FEE = $1000 / FACILITY REPAIR PLAN CHECK TANK ID#(s): $ CONSULTATION FEE = $ 125/ HOUR $ TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ spill buckets, sumps, misc. $ $ PIPING REPAIR FEE = $3751 FACILITY use for piping, under -dispenser containment, ect.) MISCELLANEOUS TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 125/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR $ SAMPLING INSPECTION FEE = $ 125/ HOUR $ ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE $ OFFICE USE ONLY SERVICE REQUEST # I FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 1/16/2013 by KF)