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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT JAN 22 2 <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sjgov.orgLeht J !moi <br /> - lL RCA !-iNA <br /> FACILITY NAME FACILITY CONTACT NAME <br /> CHEVRON SS#9-9840 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 4344 WATERLOO LANE ( 916 ) 46-9680 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> STOCKTON CA 94506 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> WAYNE PERRY,INC. MERLIN BOWEN(AGENT FOR CONTRACTOR-WAYNE PERRY) <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 30 MAIN AVE. SUITE 5 916 ) 646-9680 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> SACRAMENTO CA 95838 Closure Installation Repair Retrofit BRANDON SM6, <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) <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 /> (Plan Review and lnspections� <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 =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 390 <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE $315/FACILITY use for piping,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$106 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# CILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVEDA <br /> SIR f I I <br /> EH 23 032(REVISED 03120109) <br />