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SAN JOAQUIN COUNT' <br /> ENVIRONMENTAL HGALTI-I DEPARTIAL <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telef how: (209)468-3420 Fax: (209)468-3433 Web:www.s' 0v.ar alehd <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 STATE ZIP CODE #OF TANQSITE <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 /> Clasure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <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 /> 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 : CLOSURE FEE=$315/TANK #TANKS X$31 5= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) $ <br /> TANK ID#(s) : TEMPORARY CLOSURE�FEE= 315/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(s) : PLAN CHECK FEE=$840/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) : $ <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment„cold starts, EVR upgrades, <br /> spill buckets,sumps,misc. <br /> $ 345 <br /> PIPING REPAIR FEE _$315/FACILITY (use for piping, under dispenser containment,ect.) <br /> MISCELLANEOUS <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 APPLICANT.. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# 1 FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br />