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Imw <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 304 East Weber Avenue,3`d Floor, Stockton,CA 95202-2708 <br /> Telephone:(209)468-3420 Fax(5"'floor): (209)468-3433 Web:www.si,eoy.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> RALEY"S FUEL STATION #356 �-1 t C kt f F—L Csf F It <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 4255 E. MORADA LANE T.B D. <br /> CITY 11 STATE ZIP CODE #OF TANKS AT SITE <br /> STOCKTON I CA 95212 2 (1 ,SPLIT TANK) <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> m jCkv '5t_. & ' -f JEFFREY LEE c/o eda-design professionals <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> •() ( .805) 546-2050 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 3 c 1`1 vi <br /> IV To CA IZ Z Closure Installation Repair Retrofit <br /> ACTIVE FACILITY N/A <br /> 2000 2001 2002 2003 2004 2005 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$151 TANK �fSr I <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place N/A <br /> TANK ID#(s): CLOSURE FEE=$2791 TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) N A <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279 1 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): 1, 2A and 2B PLAN CHECK FEE_$744 P FACILITY $744'00 <br /> REPAIR PLAN CHECK N/A <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279 I FACILITY (use for monitoring equipment,spill buckets,tank sumps,mise. <br /> PIPING REPAIR FEE _$2791 FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $931 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $931 HOUR <br /> SAMPLING INSPECTION FEE _ $931 HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY /) ad <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> S� <br /> EH 23 032(REVISED 02122105) <br />