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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 Far: (209) 468-3433 Web: www.sjgov. or /g ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Speedway elizabeth Okupe <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> 401 W Kettleman Lane , Lodi CA 95240 20918m8787 <br /> CITY ISTATE I ZIP CODE # OF TANKS AT SITE <br /> Lodi CA 95206 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Service Station Systems . lnc <br /> Marty Weithman <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE #WITH AREA CODE <br /> 680 Quinn Ave . 408- 213-6038 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> San Jose CA 95112 o <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) : CLOSURE FEE = $ 315 / TANK # TANKS X $315 = $ <br /> TEMPORARY CLOSURE <br /> Pian Review and Inspections) <br /> TANK ID # (s) : TEMPORARY CLOSURE FEE = $315 / FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID # (s) : PLAN CHECK FEE $840 / FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : <br /> TANK RETROFIT REPAIR FEE = $316 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ 456 <br /> spill buckets , sumps , misc. <br /> PIPING REPAIR FEE _ $315 / FACILITY use for piping , under4s enser containment, act. $ <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 81LLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST jL FACILITY ID I AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED <br /> SR <br /> j EH 23 032 (REVISED 02/23/09) <br /> i <br /> i <br />