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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.s*gov.orPJehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Walgreens Walter Hcoutt <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> Northeast corner of Farmington Rd and E Mariposa Rd 650 689-5073 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95205 1 <br /> ' APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Farmington and Mariposa Development LLC Frank R. Poss <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> ' <br /> CITY 4703 Tidewater Avenue, Suite B 51R)434-9200 <br /> STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Installation Repair ReVotiil <br /> ACTIVE FACILITY <br /> 2006 2007 2008 2009 2010 2011 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2006.2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) --- $$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=$49.00/FACILITY $ <br /> ' PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place $� <br /> TANKID# s CLOSURE FEE_$375/TANK #TANKS X$375= x+75 <br /> ORARY CLOSURE <br /> TEMP <br /> ' Plan Review and Inspections) <br /> TANK to#(s)! TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> ' INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$1,000/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for' monitoring equipment,cold starts,EVR upgrades, $s ill buckets sum s,misc. <br /> PIPING REPAIR FEE=$375/FACILITY use for piping,under-dispenser containment,ect. $ <br /> ' MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> ' CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br /> SAMPLING INSPECTION FEE _ $125/HOUR $ <br /> ALL FEES ARE BASED ON THE 8125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $375 <br /> ' OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID IAMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> ' EH 11032(REVISED 0811111 by KF) <br />