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P`�O, <br /> Pd `t SANsdOA0UIN Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Costco#0658 Mike Sharpe, Costco Whole-sale Corp. <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3250 W Grant Line Rd 425 416-2270 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Tracy CA 95304 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ShannonJewell1 Wayne erry, Inc. Shannon Jewell <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 8281 Commonwealth Avenue 714 826-0352 <br /> CITY Buena ParkSTATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CA M621 Closure Installation epair Retrofit 5 15738# IC Ha ey <br /> ACTIVE FACILITY <br /> UST FEES= $641 Facility Fee f$152 Per Tank 2412 2013 2014 2015 2016 2017 <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$201 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$4561 TANK #TANKS X$456= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$456/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1216 1 FACILITY is <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): UDCs: 112, 314, 718, 9110, 87 T1 Vapor Bucket, 87 T2 Fill Bucket, 87 T2, Vapor Bucket <br /> TANK RETROFIT REPAIR FEE =$456 1 FACILITY (use for monitoring equipment,cold starts, EVR upgrades, $ <br /> spill buckets,sumps,mist. <br /> PIPING REPAIR FEE=$456 1 FACILITY use for piping,under-dispenser containment,ect. $ 456 <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 H C E -1 $ <br /> CONSULTATION FEE = $1521 HOUR $ <br /> J <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $152/HOUR <br /> SAMPLING INSPECTION FEE = $1521 HOUR $ <br /> FEES ARE BASED ON THE$152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID L L <br /> TOTAL AMOUNT DUE DEPARTMENT $ 456 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />