Laserfiche WebLink
0 SAN JOAQUIN COUNTY 0 <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjjzov.orp,/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />�• <br />► o►.�t' �v1v •.�Or�w�.�r�-�a-� �st_4 �+ • CAS <br />M��c �•a..`� S C-%- AL. r oV-4— <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />3,k s N. �IQ.Y- J c5,y . ,... 5--� , <br />('21,10 is S - o g O <br />CITY <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />! t-' 1c --Fm <br />CA <br />I=% a Zo 2_ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />�• <br />► o►.�t' �v1v •.�Or�w�.�r�-�a-� �st_4 �+ • CAS <br />• G 1�0.t�1 Ci• -•G v. o r�Z_ <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />I.128o i +'0►8,L - C—11ze rte <br />A k (o) - \- O *k 0 <br />CITY <br />STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />Qoan G1•o C.ordovl►• <br />C,� <br />qS'7 112_ <br />Closure Installation Repair Retrofit S -e + �� <br />n <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $366 / TANK <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2005-2007) <br />PIPING REPAIR FEE = $366 / FACILITY (use for piping, under -dispenser containment, ect.) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 122 / HOUR <br />SAMPLING INSPECTION FEE _ $ 122/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (20Q8-2010) <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 =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $366 / TANK <br /># TANKS X $366 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $366 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />I PLAN CHECK FEE = $976 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $366 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />CONSULTATION FEE _ $ 122/ HOUR <br />PIPING REPAIR FEE = $366 / FACILITY (use for piping, under -dispenser containment, ect.) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 122 / HOUR <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />CONSULTATION FEE _ $ 122/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 122 / HOUR <br />SAMPLING INSPECTION FEE _ $ 122/ HOUR <br />ALL FEES ARE BASED ON THE $122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLIGAN 1. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 07/21/10) <br />