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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:W Ww.si¢ov or0/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Costco Retail Fueling Facility Loc. No. 658 Dennis Bock <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3250 West Grant Line Road 425 313-8100 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Tracy CA 95377 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Costco Wholesale c/o <br /> Bar hausen Consulting Engineers, Inc. Alexia Dorsch <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 18215 - 72nd Avenue South 425 251-6222 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Kent WA 98032 Closure Installation Repair etro <br /> ACTIVE FACILITY <br /> 208 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 2006 2007 0 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <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=$24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$294/TANK #TANKS X$294= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$294/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$784/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> $ 294.00 <br /> TANK RETROFIT REPAIR FEE _$294/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,mist. <br /> PIPING REPAIR FEE _$294/FACILITY use for piping,under-dispenser containment,act.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $98/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $98/HOUR $ <br /> SAMPLING INSPECTION FEE = $98/HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 12/31/07) 10050.002.pdf <br />