COMPLIANCE INFO_2007-2009 - Laserfiche WebLink

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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTME* 600 East Main Street,Stockton,CA 95202-30 Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.sjgov.org/ehd FACILITY NAME FACILITY CONTACT NAME &4) J 0 CD UA�f —C40 A-PO 9 1 _X PAP AA L 0-A tJ a FACILITY ADDRESS SITE PHONE#WITH AREA CODE Pc) "5' (.Z aq) 4-6 3 0 717 CITY STATE ZIP CODE #OF TANKS AT SITE CA q S-�za t I a APPLICANT BILLING NAME APPLICANT CONTACT NAME . (,113Lie j 6 6 915A UM APPLICANT MAILING® AILING ADDRESS APPLICANT PHONE#WITH AREA CODE Pe 6. g ) "k/ lop/0 Qb-7 ) 3 6z CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC Closure Installation Q!pa_� Retrofit 15d C 540' 6'r-*/j 177 T ACTIVE FACILITY 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE+I TANK(2004-2007) $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) $ $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=$24.00/FACILITY PERMANENT CLOSURE (Removal or Permitted Closure in Place) TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315 TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE $315 FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE $840 FACILITY REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVIR upgrades, spill buckets,sumps,misc.) 3 /s7 PIPING REPAIR FEE $315/FACILITY (use for piping,under-dispenser containment,act.) MISCELLANEOUS TRANSFER FEE $20 CONSULTATION FEE $105/HOUR UNAUTHORIZED RELEASE EVALUATION FEE $105/HOUR SAMPLING INSPECTION FEE $105/HOUR ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SIR EH 23 032(REVISED 03120109)