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SAN JOAQUIN COUNTY <br />*ENVIRONMENTAL HEALTH DEPARTME <br />600 East Main Street, Stockton, CA 95202-3 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj og v.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />EI Dorado Shell <br />Bob Lutz <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2320 N EI Dorado St <br />209 943-1311 <br />CITY STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />Stockton CA <br />95209 <br />1 95213 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />HMC - Henderson Maintenance Company <br />APPLICANT MAILING ADDRESS <br />Carl Wayne Henderson <br />APPLICANT PHONE # WITH AREA CODE <br />PO Box 31325 <br />209 467-7573 <br />CITY <br />STATEZIP <br />CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Stockton <br />CA <br />1 95213 <br />Closure Installation Repair Retrofit <br />5252923 -UT <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $315 / TANK <br />2004 <br />2005 <br />2006 <br />2007 <br />2008 <br />2009 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) <br />PIPING REPAIR FEE = $315 / FACILITY use for piping, under -dispenser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $315 / TANK <br /># TANKS X $315 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />PLAN CHECK <br />n Check and <br />TANK ID # (s) : I PLAN CHECK FEE = $840 / FACILITY <br />Ej <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />$ 315.00 <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />CONSULTATION FEE _ $ 105/ HOUR <br />PIPING REPAIR FEE = $315 / FACILITY use for piping, under -dispenser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 105/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br />SAMPLING INSPECTION FEE _ $ 105/ HOUR <br />ALL FEES ARE BASED ON THE $105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED To APPLIUAN I. <br />OFFICE USE ONLY <br />SERVICE REQUEST # I FACILITY ID I AMOUNT RECEIVED I CHECK # I RECEIVED BY I DATE RECEIVED i <br />SR <br />cu t <br />