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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.simov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 7-Eleven, Inc. Jay Stemley <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 4943 South State Route 99 209 939-0679 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95206 three <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 7-Eleven, Inc. Jay Stemley <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2339 Gold Meadow Way, Suite 101 ( 9161463-6720 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Gold River CA 95670 Closure Installation Repair Retrofit see certs <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2004-2007) 2004 2005 2006 7008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$3151 TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s) : I TEMPORARY CLOSURE FEE_$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections <br /> TANK ID#(a): PLAN CHECK FEE_$8401 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) : <br /> TANK RETROFIT REPAIR FEE _$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 315 .0 0 <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$315/FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $1051 HOUR $ <br /> SAMPLING INSPECTION FEE = $105/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 REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 03/20109) <br />