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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL I- gALTH DEPARTMEA11 <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 7-Eleven #2369-14117 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 2725 Country Club Lane <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95201 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2004 2005 ZaOs Zoog Zags zoos <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2003-2008) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15!TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s) : CLOSURE FEE=$3151 TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s) : TEMPORARY CLOSURE FEE_$315 1 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$8401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$3151 FACILITY (use for monitoring equipment, cold starts,EVR upgrades, <br /> spill buckets,sumps,mist. <br /> PIPING REPAIR FEE _$315 1 FACILITY (use for piping, under-dispenser containment,ect.) $ 345 <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $ 1051 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1051 HOUR <br /> SAMPLING INSPECTION FEE _ $1051 HOUR <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> fSERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> R <br /> cu 91%azo 109:ineFn m»zrnat <br />