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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMET <br /> 600 East Main Street,Stockton,CA 95202-3 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sjgov.org/ehd <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 1 369-3633 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Lodi CA 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 1 467-7573 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Stockton CA 1 95213 Closure Installation Repair Retrofit 5252923-UT <br /> ACTIVE FACILITY <br /> 06 2007 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) 2004 2005 202008 2009 <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 /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $345. $345. $ <br /> TANK ID#(s): CLOSURE FEE=$315/TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $345. $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$315/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(a): 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 /> spill buckets,sumps,misc. <br /> $345. $ <br /> PIPING REPAIR FEE _$315/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $20 <br /> $ <br /> CONSULTATION FEE _ $105/HOUR <br /> $ <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 /> =5 9M1 049/GFVICpI M0M1/!10\ <br />