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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.sipov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Safeway Elanor Britton <br /> FACILITY ADDRESS SITE PHONE IN WITH AREA CODE <br /> 6425 N. Pacific Ave Stockton CA 95207 209-4 2-8600 <br /> CITY STATE ZIP CODE p OF TANKS AT SITE <br /> Stockton CA 95204 <br /> 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Service Station Systems, Inc. <br /> Mart 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 0 <br /> 0 5258560-UT <br /> ACTWE 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(2008) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT At ON INVENTORY IN A CUPA PROGRAM-$24.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(a): CLOSURE FEE=$315/TANK #TANKS%$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and inspect] s <br /> TANK ID N(a): TEMPORARY CLOSURE FEE=$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins .,.lions <br /> TANK ID It(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, $ <br /> s ill buckets sum misc. 345 <br /> PIPING REPAIR FEE _$315/FACILITY use for i in ,underdls ser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = 20 $ <br /> CONSULTATION FEE _ $ 105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $1D5 I HOUR $ <br /> SAMPLING INSPECTION FEE = $105/HOUR $ <br /> ALL FEES ARE BASED ON THE$106 HOURLY RATE. TIME TNAT E%CEEOS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST J FACILITY ID AMOUNT RECEIVED CHECK/ RECENED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02/23109) <br />