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0 . <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Scat, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web. www.s ,zov.org/ehd <br />FACLITY NAME <br />FACILITY CONTACT NAME <br />Circle K 170SIPY <br />ob Noway <br />FACILITY ADDRESS <br />SITE PHONE 0 WITH AREA CODE <br />1 <br />32o2 W. i4ammpe- bene <br />2oc s7-1900 <br />CITY <br />I ZIP CODE <br />I ZIP CODE <br /># OF TANKS AT SITE <br />Sto c.Kton <br />ICA <br />I gS2 0 7 <br />R i <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />(Settler- P-11cin Inc. <br />5 amwn <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE S WITH AREA CODE <br />3 lyo (repid cognio bcS : 1-70 <br />92-rSS I- -7S-S-5 <br />CITY I STATE <br />I ZIP CODE <br />I CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />C.A. <br />194-6-70 <br />1 Clbsure Insta►ladon Repair (EERb <br />S r2 of o - Ur <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE= 5 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $115 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $115/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE= 5 / TANK <br /># TANKS X $345 = <br />TEMPORARY CLOSURE <br />Plan Review and i ons <br />TANK ID fla): : <br />TE MPORARY CLOSURE FEE = $345 /FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : VbL I/ 3/ 6 -71,r Codw3 <br />$ <br />TANK RETROFIT REPAIR FEE (]e) FACILITY (use for mors wft equipment, odd swis, EVR uppredes, <br />Sys <br />will buckets, su mist. <br />$ <br />CONSULTATION FEE = $115/ HOUR <br />$ <br />PIPING REPAIR FEE = $345 / FACILITY use for , under aorrteilment, ea <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE = $115/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $115 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $115/ HOUR <br />ALL FCCS ARE BASED UN I HE *173 NUURLT NATE TI! THAT EAGEED3 FEES PAW we.L BE WU �' �' TO APPLICANT. <br />OFRCE USE ONLY <br />SERVICE REQUEST / FACILITY ID AMOUNT RECEIVED CHECK • RECEIVED SY I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 071MMM <br />