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SAN JOAQUIN COUNTY <br /> %w ENVIRONMENTAL HEALTHDEPARTMENwO' PAYMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.com %99 1 <br /> BCE#101 e ro <br /> FACILITY NAME FACILITY CONTACT NAME NOV <br /> Costco Gasoline (Loc. No.38) On-Duty Gasoline Facility Manager SAN JOAQUIN COU Mly <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE ;;,E 'JVIHQMENTAI <br /> TM <br /> 1616 E. Hammer Lane 209 478-2040 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95210 3 existing+ 1 new=4 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Barghausen Consulting Engineers, Inc. Alexia Inigues, Project Planner <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 18215-72nd Avenue South 425 251-6222 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Kent Closure Installation Repair Retrofi Out to Bid <br /> ACTIVE FACILITY <br /> 2007 2008 2009 2010 2011 2012 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$15/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$375/TANK #TANKS X$375= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY <br /> REPAIR PLAN CHECK <br /> TANKID#(s): 1,2, 3 <br /> $ <br /> TANK RETROFIT REPAIR FEE =$375/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 375 <br /> split buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$375/FACILITY use for piping,under-dispenser containment,eat. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $125/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125/HOUR $ <br /> SAMPLING INSPECTION FEE = $125/HOUR $ <br /> ALL FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $375 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATEcE <br /> !< l q I;z <br /> EH 23 032(REVISED 04/19/12 by KF) <br />