COMPLIANCE INFO_2012-2018 - Laserfiche WebLink

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e y w •f't�` ` w �,�fF ., e�=""�i�';re er � y yy e � e w 4'tF s t ",e:+-�' � �I 'y�� ie •t ! r e t r "�� ' .t y t s „ t+t� ' ��e 'Y � ` i � e t ♦ e r est ., e w ,- �i 7e � � �+ �r e t +� �. t t � t t y s , t t � t "-. s��i • �'+ � , � r " { �•, � it ` � t SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT Ll 600 East Main Street, Stockton, CA 95202-,3029 Telephone: (7.09) 463-3420 Fax: (209) 468-3433 Web: www.sjjzov.org/ehd FACILITY NAME FACILITY CONTACT NAME FACILITY ADDRESS SITE PHONE # WITH AREA CODE APPLICANT MAILING ADDRESS l a trema 1.I IfZcl CSA CITY STATE ZIP CODE # OF TANKS AT SITE CA APPLICANT BILLING NAME APPLICANT CONTACT NAME E X U. e -am u)wTf', APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA C&D-F 25th wi�,W�,�, cQ.. �c�c.�-�n CITY STATE ZIP CODE - 1. bbj CIRCLE WORK TO BE DONE CONTRACTOR ICC # 2011 Closure- Installation Wp-aYr Retrofit PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID #.(s): CLOSURE FEE= $375,, 4 K # TANKS -X $375 = $500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) $125 PER TANK AFTER FIRST TANK 2006 2007 2008 2009 2010 2011 $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 /TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID #.(s): CLOSURE FEE= $375,, 4 K # TANKS -X $375 = TEMPORARY CLOSURE Plan Review and inspections) TANK ID # (s) : IT EMPORARY CLOSURE FEE = $375 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID # (s) : PLAN CHECK FEE _ $1,000 / FACILITY $ REPAIR PLAN CHECK TANK ID # (s) : - $ _ TANK RETROFIT REPAIR FEE - $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, s ill buckets, sum s, mise. -I-PIPING-REPAIR FEE - $375 /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 FEESAREBASED ON THE $125 HOURLY RHTE. TIME THATEXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE $ OFFICE USE ONLY — ;ERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED :H 23 032 (REVISED 08N/11 by KF) "