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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: wWww.sigov.ore/ehd lire 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 rnl.�LI I T I. N IAU I NAME USA Pauline FACILITY ADDRESS SITE PHONE # WITH AREA CODE 10858 Trinity Parkway, Stockton CA 95219 (209-9)2-2213 CITY STATE ZIP CODE # OF TANKS AT SITE Stockton CA 95204 3 APPLICANT BILLING NAME APPLICANT CONTACT NAME .Mart Service Station Syste;;nc Weithman APPLICANT MAILING ADDS 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 �i 5258560 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 TEMPORARY CLOSURE # TANKS X $315 = Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $315 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Ins ections 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, $ --;I] buckets, sum s, misc. 375 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 5105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. )FFICE USE ONLY ;ERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED 'R H 23 032 (REVISED 02/23109)