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SAN JOAQUIN COUNTY `-e <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sigov.org-/chd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> COSTCO GASOLINE (LOC. NO. 1091) On Duty Gasoline Facility Manager <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 2680 REYNOLDS RANCH PARKWAY 209 366-7300 <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> LODI ICA 95240 1 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> BARGHAUSEN CONSULTING ENGINEERS, INC. ALEXIA INIGUES <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 18215 72ND AVENUE SOUTH 425 251-6222 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repqr Retrofit <br /> ACTIVE FACILITY <br /> 2007 2008 2009 2010 1 2011 2012 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) $ <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=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$375/TANK #TANKS X$375= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$1000/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 375 <br /> spill buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$375/FACILITY use for piping,under-dis nser containment,act. <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$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE Is 375 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID 1 AMOUNT RECEIVED CHECK# I RECEIVED kY DATE RECEIVED <br /> L2,00 3 $ <br /> EH 23032(REVISED 04/13112 by KF) <br />