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SAN JOAQUIN COUNTY �^`�' <br /> • ENVIRONMENTAL HEALTH DEPARTME• L � ��` j, <br /> 600 East Main Street,Stockton,CA 95202-3029 ( <br /> Telephone:(209)468-3420 Fax:(209)468.3433 Web:www.sigoy.org/chd <br /> FACILITY NAME )5 <br /> FACILITY CONTACT NAME <br /> Rancho San Miguel Market(Food for Less) -LP S 0,S L,(0 <br /> TAS <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> nrli- <br /> 1409 S. Airport Way, Stockton CA 95206 209-9 2-2840 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95206 <br /> 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Service Station Systems, Inc. <br /> Mart Weithman <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 680 Quinn Ave. 408 213-6038 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC 9 <br /> San Jose CA 95112 0 <br /> 8033115 <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2003.2008) 2004 2005 2006 2007 2008 2009 <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 Permltted 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/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and ConsVuction Ins ections <br /> TANK ID#(s): PLAN CHECK FEE_$840/FACILITY $ <br /> REPAIRPLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE _$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ 390 <br /> spill buckets,sums mist. <br /> PIPING REPAIR FEE _$3151 FACILITY use for 2ipin2.under-dispenser containment.act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 aAPP-LICANT.CONSULTATION FEE _ $ 105/HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $ 105/HOURSAMPLINGINSPECTION FEE _ $ 105/HOUR ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLEDTO <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID 1 AMOUNT RECEIVED I CHECK M 1 RECEIVED BY DATE flECEiYED <br /> SR <br /> EH 23 032(REVISED 02123109) <br />