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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.s ov.or lehd <br /> FACILITY NAME FACfLITY CONTACT NAME <br /> Rancho San Miguel (Food 4 Less) Gilbert Silva <br /> FACILITY ADDRESS SITE PHONE IN WITH AREA CODE <br /> ;;;�; <br /> 1409 S.Airport Way Stockton CA 95206 (209-912-2840 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95206 <br /> 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Service Station Systems, Inc. <br /> Marty Weithman <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 680 Guinn Ave. <br /> 408 213-6038 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> San Jose CA 95112 0 E� 5258560 <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=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=a315 i TANK IY TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s); TEMPORARY CLOSURE FEE_$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$840/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FLEE =$315 1 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ 375 <br /> --411 buckets,sum s,mist. <br /> PIPING REPAIR FEE =$315/FACILITY use For piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $ 1051 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 1.051 HOUR $ <br /> SAMPLING INSPECTION FEE _ $ 105!HOUR $ <br /> ALL FEES ARE BASED ON THE;1D5 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLEDTO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE RPCtUES FACILITY ID AMOUNT RECEIVED CHECK M RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02723109) <br />