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� ps•.,.-s 4, M. <br /> SAN JOAQUIN COUNTY °@) q '�• m a 1`a; �: .D <br /> ENVIRONMENTAL HEALTH DEPARTMENT _ <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 FEB 12 2018 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.com <br /> FACILITY NAME FACILITY CONTACT NAME ,AL- HEALTH <br /> Chevron Debbie PAM T ,/i�INT <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3775 N Tracy Boulevard 209 836-9427 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Tracy CA 95304 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Me an Mitchell <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr (209 ) 461-6337 <br /> CIN STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Stockton a Closure Installation Repair Retrofit <br /> ACTNE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+i TANK 2010 2011 2012 2013 2014 2015 <br /> $130 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM$35.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID#(s): CLOSURE FEE=$390/TANK #TANKS X$390= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$3901 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$10401 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$390!FACILITY (use for monitoring equipment,cold starts.EVR upgrades, 684.00 <br /> spill buckets,sumps,mist <br /> PIPING REPAIR FEE=$390/FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $1301 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1301 HOUR $ <br /> SAMPLING INSPECTION FEE = $130/HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $684.0 <br /> OFFICE USE ONLY <br /> SERVICE REQUESTA I FACILITY ID I AMOUNT RECEIVED CHECKA RECENED BY DATE RECEIVED <br /> EH 23 032(REVISED 04-22.15) <br />