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SAN JOAQUIN COUNTY <br /> �.. ENVIRONMENTAL HEALTH DEPARTWNof PAYMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 RECEIVED <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www sicchd.comBCE#1 n n <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Costco Gasoline(Loc. No.38) On-Duty Gasoline Facility Manager SAN JOAQUIN COUP TY <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1616 E. Hammer Lane 1 209 478-2040 <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 /> ent Closure nstallatiog Repair Rat I Out to Bid <br /> ACTIVE FACILITY <br /> 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) 2010 2011 1 2012 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2009-2012) <br /> $125 PER TANK AFTER FIRST TANK $125 <br /> $ <br /> TANK PENALTY ASSESSED <br /> $15 <br /> TANK SURCHARGE=$15/TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$375/TANK #TANKS X$375= <br /> TEMPORARYCLOSURE <br /> Plan Review and Ins ections <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): 4 PLAN CHECK FEE=$1000/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$3751 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$375/FACILITY use for piping,under-dispenser containment,act. <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 $1,140 <br /> OFFICE USE ONLY <br /> SERVICEREQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# RECEIVE BY I DATER CE D <br /> EH 23 032(REVISED 04/13/12 by KF) <br />