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SAN'JOAQUIlV COUNTY <br /> E00NVIRONMENTAL HEALTH DEPARTMEN <br /> East Main Street,Stockton,CA 95202-30 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.si¢ov.or ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 7-Eleven #2368-32190 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 4943 S State Hwy 99 209 939-0679 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95215 3 <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 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2.;.... $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$24.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(a): CLOSURE FEE=$315/TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(a): 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#(a): <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> $ 315 <br /> PIPING REPAIR FEE _$315/FACILITY use for piping, under-dispenser containment,act. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $105/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR <br /> $ <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# I FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> SR <br /> cu na nao ke=knUn nw,wnai <br />