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- SAN JOAQUIN CO' Y PUBLIC HEALTH SERVICES-ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRO�.+D STORAGE TANK PROGRAM f : WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Safeway , Inc. Mike Vandergrift <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> aci is Ave (209)475-9987 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95205 <br /> E5918Stone <br /> PLICANT BILLING NAME APPLICANT CONTACT NAME <br /> . Chase Jiannalole <br /> ICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> id e STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> CA 94588 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1996- 1999 2000 2001 <br /> $500 FEE INCLUDES FACILITY FEE+ I TANK (9170)X(#tanks)X I#of years applicable) <br /> $125 PER TANK AFTER FIRST TANK $ i <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$8/TANK <br /> $ $ '�� 1 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=S10/FACILITY $10.00 <br /> PERMANENT CLOSURE " EXPEDITED <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=S261 /TANK #TANKS X S261 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) $ <br /> TANK ID#(s) : TEMPORARY CLOSURE FEE=$261 /FACILITY j <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ t <br /> TANK ID#(s): PLAN CHECK FEE_$696/FACILITY j <br /> REPAIR PLAN CHECK <br /> TANK ID# s): $ # <br /> TANK LINING REPAIR FEE =$261 /TANK #TANKS X$261 = <br /> $ <br /> TANK RETROFIT REPAIR FEE =$261 /FACILITY $ <br /> PIPING REPAIR FEE _$261 /FACILITY <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE = S20 $ <br /> CONSULTATION FEE _ $87/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $871 HOUR $ <br /> SAMPLING INSPECTION FEE _ $87/HOUR <br /> ALL FEES ARE BASED ON THE$87 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> 17 SERVICE REOUE9T# I FACILITY 10 AMOUNT RECEIVED I CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 2-e-011 <br />