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SAN JOAQUIN COUNTY `r <br /> ENVIRONMENTAL HEALTH DEPARTMENT �r' p' ,� 3a <br /> 600 East Main Street, Stockton,CA 95202-3029 9 r ,-'b�,f` � <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www sigov ore/ehd <br /> ;610S <br /> FACILITY CONTACT NAME 10 <br /> San MguelJesus JuradoADDRESSSITE PHONE N WITHerokee Lane,Lodi 209-3 9-8200 <br /> STATE ZIP CODE N OF TANKS AT SITE <br /> CA 95240 <br /> 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Service Station Systems, Inc. <br /> Marly Weithman <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE'#WITH AREA CODE <br /> 680 Quinn Ave. 408 213-6038 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC N <br /> San Jose CA 95112 <br /> f7 F <br /> 8057571 <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE- 1 TANK(2003-2008) 2004 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE- 1 TANK(2009) <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=$24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK IDN(a): CLOSURE FEE=$315/TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ina Cions <br /> TANK ID It(a): TEMPORARY CLOSURE FEE=$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID N(s) PLAN CHECK FEE_$8401 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$3151 FACILITY (use for mo ring equipment,cold starts.EVR upgrades, $ <br /> s ill buckets sum s mist,) 390 <br /> PIPING REPAIR FEE _$315 1 FACILITY use for piping.under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE : $20 $ <br /> CONSULTATION FEE _ $ 1051 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 1051 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 REOU EST# FACILITY ID AMOUN7 RECEIVED CHECK N RECENED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 03/27109) <br />