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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.sigov.org/ehd FACILITY NAME FACILITY CONTACT NAME Speedway Mona FACILITY ADDRESS SITE PHONE#WITH AREA CODE 2500 W Lodi, Lodi 95242 209-3q6-0703 CITY STATE ZIP CODE #OF TANKS AT SITE Lodi CA 95242 4 APPLICANT BILLING NAME APPLICANT CONTACT NAME Service Station Systems.lnc Marty Weithman APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE 680 Quinn Ave. 408- 213-6038 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# San Jose CA 95112 0 • ACTIVE FACILITY $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2003-2008) 2004 2005 2006 2007 2008 2009 $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): TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ 456 spill buckets,sumps,misc. PIPING REPAIR FEE =$315/FACILITY use for piping,under-dispenser containment,ect. $ 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# FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVEp BY DATE RECEIVED SR EH 23 032(REVISED 02123/09)