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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.Sjgov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Gas 4 Less Jesus Jurado <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3434 Manthey Rd, Stockton CA 95206 209-2 4-7889 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95206 <br /> 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Service Station Systems, Inc. Marty Weithman <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 680 Quinn Ave. <br /> 408 213-6038 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> San Jose CA 95112 <br /> 0 8022810 <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2003-2008) 2004 2005 2COfi 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 /> Plan Revlew and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): 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, $ 390 <br /> spill buckets,sumps,misc. <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$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED To APPLICANT. <br /> 77 <br /> OFFICE USE ONLY <br /> MSERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK N RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/23/09) <br />