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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Stmet,Stockton,CA 95202-3029 <br /> Telephone.(209)468-3420 Fox.(209)468-3433 Web:www-si92yjo�ehd <br /> FACILITY NAME IF"NAME <br /> FACILITY <br /> Chevron Andrea Vilchis <br /> FACtUTY ADDRESS SITE PHONE#WIT44 AREA CODE <br /> 1103 S.Main St,Manteca CA 95337 (209-815-0174 <br /> CITY STATE ZIP CODE F TANKS AT SITE <br /> Stockton CA 95337 3 <br /> APPLICANT BILLING—NAME <br /> _APPLICANT CONTACT NAME <br /> Service Station Systems, Inc. <br /> Mart v Weithman <br /> APPLICANT MAILING <br /> APPLICANT PHONE WITH AREA CODE <br /> 680 Quinn Ave. <br /> (408 )213-6038 <br /> CITY STATE ZIP CODE - CIRCLE-WORK TO BE DON- CONTRACTOR ICC# <br /> San Jose CA 95112 E 5258558-UT <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+I TANK(2003.2008) 2004 2005 2006 i 2007-—20-08 2009 <br /> $550 FEE INCLUDES FACILITY FEE+I TANK(2009) <br /> $126 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> fSTATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(a): CLOSURE FEE=$315/TANK #TANKS X$315 <br /> TEMPORARY CLOSURE <br /> (Plan Review and InspecGon?l <br /> TANK ID#(s): --f-TEMPORARY CLOSURE FEE=$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$840/FACILITY L <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ 366 <br /> spOl buckets,sump!,misc.PIPING REPAIR FEE =$3151 FACILITY use for n under-disser containment,a $ <br /> penact.)ct <br /> MISCELLANEOUS <br /> TRANSFER FEE = $20 $ <br /> CONSULTATION FEE = $ 105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE $105 t HOUR $ <br /> SAMPLING INSPECTION FEE = $1051 HOUR I $ <br /> ALL FEES ARE BASED ON THE$105 Houny—RATE. TI-M-1 THAT EXCEEDS FEES PAID WILL BE BILLED To—APPLICANT, <br /> OFFICE USE ONLY <br /> -SERVICE REQUEST# — FACILITY toAMOUNT RECEIVEDI CHECKS RECEIVED BY DATE REC$IVED � <br /> SIR IEM 23 032(REVISED 02n3109) <br />