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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 sMov ore/chd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Fast Lane Central Valley Robert Cabigas <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 116 E Roth Rd. Lathrop CA 95330 209-2 4-4341 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95204 <br /> 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Service Station Systems, Inc. Mart Weilhman <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 680 Quinn Ave. 408 213-6038 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> San Jose CA 95112 0 <br /> 0 5261142-UT <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) M <br /> 8 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009) <br /> $125 PER TANK AFTER FIRST TANK $TANK PENALTY ASSESSED $TANK SURCHARGE=$151 TANK $STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INCILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Cbsure in Place <br /> TANK ID# s CLOSURE FEE=531,S/TA NK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Pian Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <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, $ <br /> split buckets sums misc.)366 <br /> PIPING REPAIR FEE =$315/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $ 1051 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 10 I AMOUNT RECEIVEDCHECK# RECENED BY DATE RECEIVED <br /> SR <br /> EN 23 032(REVISED 02/23/09) <br />