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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDESGROUND STORAGE TANK PROGRAM FAkWORKSHEET <br /> FACIUMME R CILITY CONTACT NAME <br /> 7-Eleven#32190 Jivtesh S.Gill <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 4943 South State Route 99 209-939-0679 <br /> CITY STATE ZIP CODE #OF TANKS @ SITE <br /> Stoctkon California 95206 3 <br /> APPLICANT BILLING NAME (Wo#123843) APPLICANT-CONTACT NAME <br /> Sacramento Equipment Maintenance Company,Inc. Linda Steiger <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2533 Connie Drive 916-925-2716 <br /> CIN STATE ZIP CIRCLE WORK TO BE DONE: Contractors ICC# <br /> Sacramento CA 95815 Closure Installation REDair Rett 5257346-US/UT <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2000 2001 2002 2003 2004 2005 <br /> $125 PER TANK AFTER FIRST TANK <br /> 5 <br /> TANK PENALTY ASSESSED s <br /> TANK SURCHARGE=$15/TANK s <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY S <br /> PERMANENT CLOSURE <br /> (Removal of Permitted Closure in Place) <br /> TANK ID#(S): CLOSURE FEE=$279/TANK #TANKS x$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(S): TEMPORARY CLOSURE FEE=$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> cJ <br /> TANK RETROFIT REPAIR FEE=$279/FACILITY(use for monitoring equipment,spill buckets,tank sumps,misc) $ -279-W <br /> PIPING REPAIR FEE=$279/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE =$20 $ <br /> CONSULTATION FEE =$93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _$93/HOUR $ <br /> SAMPLING INSPECTION FEE =$93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK* RECEIVED BY DATE RECENED <br /> SR <br /> EH 23 032(Revised 02/22/05) <br /> V:\county\San 3caquin\env\forms\permits\repairs4-fee worksheet <br />