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• SAN JOAQUIN COUNTY • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.si2ov.org/eh <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 7-Eleven/76 Lodi Jivtesh Gill <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1111 E Kettleman Ln 209 369-3633 <br /> cln <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> Lodi CA 1 95240 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> HMC -Henderson Maintenance Company Carl Wayne Henderson <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> PO Box 31325 209 467-7573 <br /> RCLE W <br /> CITY STATE ZIP CODE CIORK TO BE DONE CONTRACTOR ICC# <br /> Stockton CA 95213 Closure Installation Repair Retrofit 5252923-UT <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK 2008) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009) $ <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15!TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place $345. $345. $ <br /> TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ctions <br /> $345. $ <br /> TANK ID#(s): TEMPOF:ARY CLOSURE FEE_$315/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$840/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> $345. <br /> TANK RETROFIT REPAIR FEE _$315/FACILITY (use for monitoring equipment cold starts,EVR upgrades, 345.00 <br /> s ill buckets,sum s,misc. <br /> PIPING REPAIR FEE _$315!FACILITY (use for i in ,under-dis enser containment,ed. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $1051 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR $ <br /> SAMPLING INSPECTION FEE _ $105/HOUR <br /> ALL FEES ARE BASED ON THE E105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPOCANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY IO AMOUNT RECEIVED —FC—HECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02123109) <br />