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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 sieov.ore/ehd <br />NAME <br />TANK ID # (s): CLOSURE FEE = $315 / TANK # TANKS X $315 = <br />TEMPORARY CLOSURE <br />ffFACILITY <br />FACILITY CONTACT NAME <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />130 S. Wilson Way <br />CITY <br />—(209-416-6633 <br />STATE ZIP CODE # OF TANKS AT SITE <br />Stockton <br />CA 95206 <br />2 <br />AFF LIUAN I BILLING NAME APPLICANT CONTACT NAME <br />Service Station Systems, Inc. Mark Shaw <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />680 Quinn Ave. <br />916 503-2538 <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTEICC <br />San Jose CA 95112 <br />0 8022810 <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) 2004 2005 2006 2007 2008 2009 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009) <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 />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSURE FEE = $315 / TANK # TANKS X $315 = <br />TEMPORARY CLOSURE <br />anReview and Ins ctionsNK <br />ffID # (s) : <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections <br />PLAN CHECK FEE = $840 / 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 />—ill buckets, sum s, mist. <br />PIPING REPAIR FEE = $315 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 105/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 105 / HOUR <br />SAMPLING INSPECTION FEE = $ 105/ HOUR <br />ALL FEES ARE BASED ON THE Sins HOURLY RATE TILP TWAT <br />FFICE USE ONLY <br />$ <br />$ <br />390 <br />$ <br />ERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />,R <br />H 23 032 (REVISED 02/23/09) <br />