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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 Fox: (209) 468-3433 Web: www.sieov ore/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Safeway <br />Julia Pollick <br />FACILITY ADDRESS <br />SITE PHONE* WITH AREA CODE <br />6425 N Pacific Ave, Stockton CA 95207 <br />209-4 2-8600 <br />CITY STATE <br />LP CODE to TANKS AT SITE <br />Stockton CA <br />95207 <br />3 <br />Service Station Systems, Inc. <br />Marty Weithman <br />680 Quinn Ave. <br />213-6038 <br />San Jose ICA 95112I D I I F- EO]8049070 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009) <br />$125 PER TANK AFTER FIRST TANK <br />i9/• <br />IN5TALLATION PLAN CHECK <br />0 (s) : <br />TANK RETROFIT REPAIR FEE = $3151 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, I $ 375 —1 <br />sn91 n��.o-ar= .,.,...,. _.-_, <br />I nnnv MCMIn ret = 4010 / t-AUILITY (use for plpmg under -dispenser containmen <br />YIR( FI <br />1PPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST• FAFJI j AMOUNT RECEIVED CHECK M IRECENEO BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 02123109) <br />TRANSFgFEE= <br />$ <br />CONSUL$ 105/ HOUR <br />$ <br />UNAUTH EVALUATION FEE _ $ 1D5 / HOUR <br />$ <br />SAMPLINE _ $ 105/ HOUR <br />ALL FEES ARE BASED ON THE 5105 HOURLY RATE. TIME THAT EKCEEOS FEES P•ID Wu i wF wn i en,.. <br />$ <br />1PPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST• FAFJI j AMOUNT RECEIVED CHECK M IRECENEO BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 02123109) <br />