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`e SAN JOAQUIN COUNTY 1"/ <br /> ENVIRONMENTAL HEALTH DEPARTMEN x) y7 6�IF <br /> S <br /> 600 East Main Street,Stockton,CA 95202-30 o NN..��iiiVVV.�) <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.s' 20U56 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Woodbridge Arco Jessie Bola ENVIRON"gERTAL HEALTH <br /> FACILITY ADDRESS SITE PHONE#WITH AREALtEib <br /> 18806 Lower Sacramento Rd,Woodbridge CA95258 209-3 9-8238 <br /> CITY STATE LIP CODE #OF TANKS AT SITE <br /> Woodbridge CA 95258 <br /> APPLICANT BILLING NAME I APPLICaPHONE <br /> ME <br /> Service Station Systems, Inc. Mart <br /> APPLICANT MAILING ADDRESS APPLICAREA CODE680 Quinn Ave. 408-CITY STATE ZIP CODE CIRONE CONTRACTOR ICC# <br /> San Jose CA 95112 g3g4903 <br /> ACTIVE FACILITY <br /> 2004 2005MFACILITY <br /> $500 FEE INCLUDES FACILITY FEE t 1 TANK(2003-2008) <br /> $550 FEE INCLUDES FACILITY FEE• 1 TANK(2009) <br /> $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE=$151 TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUP <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(a): CLOSURE FEE=$315/TANK III TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> TANK ID If(s): TEMPORARY CLOSURE FEE_$315/FACILITY $ <br /> INSTALLATN PLAN CCK <br /> Plan Check anIOd ConsHE <br /> truction Inspections)TANK ID#(s): PLAN CHECK FEE_$840/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipmen;wntalnmeni, <br /> midnect.) <br /> $ <br /> --M buckets sum s mist. 417 <br /> PIPING REPAIR FEE _$315/FACILITY usa forpiping,under-dispenser n $ <br /> MISCELLANEOUS <br /> TRANSFERFEE _ $20 $ <br /> CONSULTATION FEE = $105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1051 HOUR $ <br /> SAMPLING INSPECTION FEE = $1051 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 REQ I AMOUNT RECEIVED ICHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02123/09) <br />