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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES- ENVIRONMENTAL HEALTH DIVISION <br />UND5lRnlINf1CTnDAGCTA1UVoonc0AR.vr Aff...,1- <br />---- ---- — <br />FACILI MEE <br />E7 <br />— — <br />vvr�e�rr r YVRRJrICCI <br />r CILITY CONTACT NAME <br />-Eleven #32190 <br />APPLICANT MAILING ADDRESS <br />2533 Connie Drive <br />JVtesh S. Gill <br />2005 <br />FACILITY ADDRESS <br />CITY <br />Sacramento <br />STATE <br />CA <br />SITE PHONE # WITH AREA CODE <br />4943 South State Route 99 <br />Contractors ICC # <br />209-939-0679 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS @ SITE <br />Stoctkon <br />California <br />95206 <br />3 <br />APPLICANT BILLING NAME (Wo #126686) <br />APPLICANT CONTACT NAME <br />Sacramento Eauioment Maintenance COIIIDanV Inc <br />Linda Steiner <br />APPLICANT MAILING ADDRESS <br />2533 Connie Drive <br />APPLICANT PHONE # WITH AREA CODE <br />2005 <br />916-925-2716 <br />CITY <br />Sacramento <br />STATE <br />CA <br />ZIP <br />95815 <br />CIRCLE WORK TO BE DONE: <br />Contractors ICC # <br />Closure Installation RCDai Retrofit <br />5257346-113/UT <br />ACTIVE FACILITY <br />TANK IO # (S): <br />$ 500 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ 125 PER TANK AFTER FIRST TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$ <br />SAMPLING INSPECTION FEE = $ 95 / HOUR <br />$ <br />ALL FEES ARF RASFD nN THF t 01 Rni 101 v Berg rrm= run+ N�==Ao a« ,..... -.---- _ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $ 15 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM = $24.00 / FACILITY <br />$ <br />PERMANENT CLOSURE <br />(Removal of Permitted Closure in Place) <br />TANK IO # (S): <br />CLOSURE FEE = $ 285 / TANK <br /># TANKS x$285— <br />$285TEMPORARY <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (S): <br />TEMPORARY CLOSURE FEE = $285 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s): PLAN CHECK FEE = $760 / FACILITY <br />I <br />REPAIR PLAN CHECK <br />FACILITY ID <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $ 285 / FACILITY (use for monitoring equipmen4 spill buckets, tank sumps, mist) <br />CONSULTATION FEE = $ 95 / HOUR <br />PIPING REPAIR FEE = $ 285 / FACILITY (use for piping, under -dispenser containment, act.) <br />$ <br />MISCELLANEOUS <br />FACILITY ID <br />TRANSFER FEE = $ 20 <br />CHECK# <br />CONSULTATION FEE = $ 95 / HOUR <br />DgTE RECEIVED <br />SR <br />EH 23 032 (Revised 01/29/071 <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 95 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 95 / HOUR <br />$ <br />ALL FEES ARF RASFD nN THF t 01 Rni 101 v Berg rrm= run+ N�==Ao a« ,..... -.---- _ <br />•. •. 1 LA. =Uo . L.a PAID WILL BE BILLED Tu <br />OFFICE USE ONLY <br />SERVICE REQUEST# <br />FACILITY ID <br />AMOUNT RECEIVED <br />CHECK# <br />RECEIVED BY <br />DgTE RECEIVED <br />SR <br />EH 23 032 (Revised 01/29/071 <br />V: \ county \ San Joaquin \ env \ forms \ Permits \ apajls fee worksheet <br />ORIGINAL <br />