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• SAN JOAQUIN COUNTY ENVIRONMEN'T'AL.HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax. (209)468-3433 Web:www.sjgov.orelehd FACILITY NAME FACILITY CONTACT NAME US Gasoline FACILITY ADDRESS SITE PHONE#WITH AREA CODE 749 E MLK(Formerly Charter Way) 209 465-8979 CITY STATE ZIP CODE #OF TANKS AT SITE Stockton CA 95206 APPLICANT BILLING NAME APPLICANT CONTACT NAME HMC- Henderson Maintenance Company Carl Wayne Henderson APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE PO Box 31325 209 467-7573 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Stockton CA 1 95213 Closure Installation Repair Retrofit 5252923-UT 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=$15 1 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 Ins ections TANK ID#(s) TEMPORARY CLOSURE FEE_$315 1 FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(s): PLAN CHECK FEE_$840/FACILITY REPAIR PLAN CHECK TANK ID#(s) $345. � TANK RETROFIT REPAIR FEE =$315 1 FACILITY (use for monitoring equipment,cold starts, EVR upgrades, spill buckets,sumps,mist.) 345.00 $345. $ PIPING REPAIR FEE _$315 I 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 REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 02123109)