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SAN 30AQUIN COUNTY <br /> ENVIRONMENTAL IIEALTH DEPARTMENT <br /> 1865 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fur:(209)468-3433 Ifleb:www.sjcehd.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Emils Liquor Chacko Thomas <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1405 California St 209 499-4693 <br /> CITY STATE I ZIP CODE I #OF TANKS AT SITE <br /> Escalon I CA 195320 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Megan M <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr 209 461-6337 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Stockton I Ca Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2010 2011 2012 2013 2014 2015 <br /> $130 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=$35.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$390/TANK #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$1040/FACILITY <br /> REPAIR PLAN CHECK <br /> V. <br /> TANK ID#(s): ; 1 <br /> TANK RETROFIT REPAIR FEE _$390/FACILITY (use for monitoring equlpmitQs E41R1ipgrades, 456.00 <br /> spill buckets,sumps,misC <br /> PIPING REPAIR FEE_$390/FACILITY use for piping,under-dispenser containmeni;'e4. <br /> MISCELLANEOUS - �� <br /> $ <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE _ $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130/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 DUET <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 04.22.15) <br />