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• SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton,CA 95202-3029 Telephone: (209)468-3420 Fax: (209)468-3433 Web:www sieov.orglehd FACILITY NAME FACILITY CONTACT NAME 7-Eleven #2368-32190 FACILITY ADDRESS SITE PHONE#WITH AREA CODE 4943 S State Hwy 99 209 939-0679 CITY STATE ZIP CODE #OF TANKS AT SITE Stockton CA 95215 3 APPLICANT BILLING NAME APPLICANT CONTACT NAME APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# 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=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY PERMANENTCLOSURE Removal or Permitted Closure in Place $ TANK IO# s CLOSURE FEE=$315/TANK #TANKS X$315= TEMPORARY CLOSURE Plan Review and Ins ections $ TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(s): PLAN CHECK FEE=$8401 FACILITY REPAIR PLAN CHECK TANK ID#(a): $ TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, s ill buckets,sum s,misc. $ 375 PIPING REPAIR FEE _$315/FACILITY (use for i in ,under-dispenser containment,act.) MISCELLANEOUS $ TRANSFER FEE _ $20 $ CONSULTATION FEE _ $105/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $1051 HOUR $ SAMPLING INSPECTION FEE _ $105/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# 1 FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 02/23/09)