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• SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone,(209)468-3420 flax:(209)466-3433 Web:www.sigov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Rancho San Miguel Market Gilbert Silva <br /> F CIL.ITY ADDRESS SITE PHONE#WITH AREA CODE <br /> to.jJ&S.Airport Way j209-942-2840 <br /> CITY `TATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95212 2 <br /> APPLICANT BILLING NAME I APPLICANT CONTACT NAME <br /> Service Station Systems, Inc. Marty Weithman <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 680 Quinn Ave. <br /> 408 213-6038 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE r CONTRACTOR ICC# <br /> San Jose CA 95112 <br /> 8148891 <br /> ,ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2043-2408) 2004 2005 1 n-06 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:$151 TANK $ <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#Is): CLOSURE FEE_$3151 TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$315 f FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$840 l FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$3151 FACILITY (use for monitoring aquipmeni,cold starts.EVR upgrades, $ 375 <br /> spilt buckets sums misc. <br /> PIPING REPAIR FEE =$315 1 FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $2D <br /> CONSULTATION FEE = $ 1051 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 105/HOUR <br /> SAMPLING INSPECTION FEE = $105!HOUR ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT.mu <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02123109) <br />