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SAN JO.AQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT — 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:w-ww.sj.gov.org/ehd FACILITY NAME FACILITY CONTACT NAME 7—Eleven ##2369-14117 FACILITY ADDRESS SITE PHONE#WITH AREA CODE 2725 Country Club Vane CITY STATE ZIP CODE #OF TANKS AT SITE Stockton 95201 2 CA APPLICANT BILLING NAME APPLICANT CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR IGC# Closure Installation Repair Retrofit ACTIVE FACILITY 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) $550 FEE INCLUDES FACILITY FEE+1 TANK(2009) $ $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE=$151 TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00!FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place $ TANK ID#(s): CLOSURE FEE=$3151 TANK #TANKS X$315= TEMPORARY CLOSURE Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE=$315 I FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE=$840 I FACILITY REPAIR PLAN CHECK TANK ID#(s) : TANK RETROFIT REPAIR FEE =$315 1 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, spill buckets,sumps,misc. $ 375 PIPING REPAIR FEE _$3151 FACILITY use for piping,under-dispenser containment,ect. MISCELLANEOUS TRANSFER FEE _ $20 CONSULTATION FEE = $1051 HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $105/HOUR SAMPLING INSPECTION FEE = $1051 HOUR ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE 79977— FACILITY ID AMOUNT RECEIVED CHECK P RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 02/23109)