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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sslgov.orR-/ehd FACILITY NAME FACILITY CONTACT NAME Freeway Shell FACILITY ADDRESS SITE PHONE#WITH AREA CODE 7700 E Moreland Ct CITY STATE ZIP CODE #OF TANKS AT SITE Stockton CA 95212 APPLICANT BILLING NAME APPLICANT CONTACT NAME Service Station Testing-SST INC Carl Wayne Henderson APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE PO Box 31465 209 465-5577 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Stockton CA 95213 Closure Installation Repair Retrofit 5252923-UT ACTIVE FACILITY 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) $550 FEE INCLUDES FACILITY FEE+1 TANK(2009) $ $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE=$15/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID# s CLOSURE FEE=$315/TANK #TANKS X$315= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(s): PLAN CHECK FEE=$840/FACILITY REPAIR PLAN CHECK TANK ID#(s): -We.— $ TANK RETROFIT REPAIR FEE =$ CILITY (use for monitoring equipment,cold starts,EVR upgrades, 7 spill buckets,sumps,misc. t3 $366. $ PIPING REPAIR FEE _$315/FACILITY (use for piping,under-dispenser containment,ed. MISCELLANEOUS $ TRANSFER FEE _ $20 CONSULTATION FEE _ $105/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR $ SAMPLING INSPECTION FEE _ $105/HOUR ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 02123109)