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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.sjpov.or2/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Shell (Tesoro) <br />Mary Morgan <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2448 W Kettleman Lane Lodi CA 95242 <br />209-7 7-0823 <br />CITY STATE <br />ZIP CODE <br />#!5T TANKS AT SITE <br />Lodi <br />CA <br />95242 <br />3 <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />Service Station Systems, Inc. Marty Weithman <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />680 Quinn Ave. <br />408 213-6038 <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC <br />San Jose CA 95112 0 <br />0 5258560 <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) 2004 2005 2006 2007 2008 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 />TANK ID # (s) : <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />= $315 / TANK I # TANKS X $315 = I $ <br />TEMPORARY CLOSURE FEE = $315 / FACILITY <br />PLAN CHECK FEE = $840 / F <br />REPAIR PLAN CHECK <br />TANK ID # (s) <br />TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts. EVR upgrades, <br />s ill buckets, sum s, misc. <br />PIPING REPAIR FEE = $315 / FACILITY use for pi2in2, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE = $ 105/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 105 / HOUR <br />SAMPLING INSPECTION FEE = $ 105/ HOUR <br />ALL FEES ARE BASED ON THE $105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />$ <br />375 <br />$ <br />IFFICE USE ONLY <br />ERVICE REQUEST# I FACILFTY ID AMOUNT RECEIVED CHECK #RECENED BY DATE RECEIVED <br />R <br />123 032 (REVISED 02/23109) <br />