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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: www.sjgov.oralehd <br />FACILITY NAME <br />- <br />11- 111%OFX I A1, 1 NAMt <br />Chevron <br />CLOSURE FEE _ $315 /TANK # TANKS X $315 = <br />$ <br />TANK ID # (s) : <br />manager <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />FACILITY ADDRESS <br />SITE PHONE N WITH AREA CODE <br />10858 Trinity Parkway, Stockton CA 95219 <br />(209-912-2213 <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />Stockton CA <br />95219 <br />3 <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />s ill buckets, sum s, mist. <br />Able Maintenance, Inc <br />PIPING REPAIR FEE = $315 / FACILITY <br />use for pipin2, under -dispenser containment, ect <br />$ <br />Marty Weithman <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />680 Quinn Ave. <br />408 213-6038 <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR <br />ICC # <br />San Jose <br />CA 95112 <br />0 <br />0 <br />5252033 <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA <br />r-1 <br />PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />CLOSURE FEE _ $315 /TANK # TANKS X $315 = <br />$ <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />$ <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />TANK ID # (s) <br />PLAN CHECK FEE = $840 / FACILITY <br />$ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />s ill buckets, sum s, mist. <br />$ <br />375 <br />PIPING REPAIR FEE = $315 / FACILITY <br />use for pipin2, under -dispenser containment, ect <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE = $ 20 $ <br />CONSULTATION FEE _ $ 105/ HOUR $ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR $ <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR $ <br />ALL FEES ARE BASED ON THE $105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REpUEST11 FACILITY ID AMOUNT RECEIVED CHECK M RECENED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 02123/09) <br />