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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL.HEALTH DEPARTMENT <br /> 600 Ease Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax;(209)4%3433 Web:www.si2ov_OWchd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Safeway <br /> FACILITY ADDRESS SITE PHONE IM WITH AREA CODE <br /> 19,E- 7 �L S3� <br /> CITY STATE I ZIP CODE T3:F TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Service Station Systems, Inc. � J� L <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE f MATH AREA CODE <br /> 680 Quinn Ave. <br /> �� 7x13 <br /> CITY STATE AP GODS CIRCLE WORK TO$E DONE CONTRACTOR ICC f <br /> San Jose CA 95112 <br /> ACTIVE FACILITY <br /> 5500 FEE INCLUDES FACILITY FEE+1 TANK(2008-2008) 2004 2005 2008 2007 2008 2009 <br /> 5550 FEE INCLUDES FACILITY FEE f 1 TANK(20D9) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=S 151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM 6$24-OD/FACILITY $ <br /> PERMANENT CLOSURE <br /> (Removal or Perm led Closure in Ptaee <br /> TANK ID iT s • CLOSURE FEE=5315/TANK P TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Pien Revlew and I lions <br /> TANK ID#(s); TEMPORARY CLOSURE FEE_=316/FACiL1TY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$8401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID f(s): <br /> TANK RETROFIT REPAIR FEE _$3151 FACILITY (use for monftorinq equO wenl,cold alerts,EVR upgrades, $ 366 <br /> iM buckets a mist. <br /> PIPING REPAIR FEE _$3151 FACILITY fuse for plphV.under-dIspenser containment,ect) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE 20 $ <br /> CONSULTATION FEE = S 105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = 3 1051 HOUR $ <br /> SAMPLING INSPECTION FEE ■ $1051 HOUR $ <br /> ALL F£ES ARE BASED ON THE 9105 HOURLY RATE.TIME THAT EXCEEDS EES PAW WILL Me BILLED TO APPLICANT, <br /> OFFICE USE ONLY <br /> URVICERNUEST111 FACILrTYID I AMOUNT RECEIVED ICHECK f RE NED DY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02MM) <br />