Laserfiche WebLink
' SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web._ .s' o v.or <br /> ALebd- <br /> FACILIW—NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#VkqTH AREA CODE <br /> -77 lTr-- AV# 1 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure installation epair,,AetroBt <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) 2004 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(008 2o,09) <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#(a): CLOSURE FEE 0 TANKS X$345= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ctions <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$345/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins lions <br /> TANK ID (s): PLAN CHECK FEE_$920/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets;sum s misc. <br /> PIPING REPAIR FEE =$345!FACILITY use f2piping,under-dispenser containment,act. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE = $115/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $1151 HOUR <br /> SAMPLING INSPECTION FEE _ $115/HOUR <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# 1 RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07/01/08) <br />