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iSAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMEN BCE#10199 600 East Main Street, Stockton,CA 95202-3029 Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.org/ehd FACILITY NAME FACILITY CONTACT NAME Costco Gasoline Dennis Bock FACILITY ADDRESS SITE PHONE#WITH AREA CODE 1616 East Hammer Lane 209 478-2045 CITY STATE ZIP CODE #OF TANKS AT SITE Stockton CA 95210-2045 3 APPLICANT BILLING NAME APPLICANT CONTACT NAME Costco Wholesale Dennis Bock APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE 999 Lake Drive CITY STATE�ZIPCODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Issaquah WAClosure Installation epair etroflt ACTIVE FACILITY 2005 2006 2007 2008 2009 2010 $500 FEE INCLUDES FACILITY FEE+1 TANK(2005-2007) $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008-2010) $ $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=$49.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place $ TANK ID#(s): CLOSURE FEE=$366/TANK #TANKS X$366= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK ID#(s): TEMPORARY CLOSURE FEE=$366/FACILITY INSTALLATION PLAN CHECK - Plan Check and Construction Inspections) $ TANK ID#(s): PLAN CHECK FEE=$976/FACILITY REPAIR PLAN CHECK TANK ID#(s): $ TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts, EVR upgrades, spill buckets,sumps,mist. $ PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,act. MISCELLANEOUS $ TRANSFER FEE _ $25 $ CONSULTATION FEE _ $122/HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR $ SAMPLING INSPECTION FEE = $122/HOUR ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED �CHECR#�RECEI� DATE RECEIVED SR EH 23 032(REVISED 07/21/10)