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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPME <br /> ARTNT <br /> 600 East Main Sircet.Stockton.CA 95202-3029 <br /> Telephone::(209)468-3420 Fax:(20))468-3433 Meh:w%v%v.sjeov.orJchd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Costco Gasoline Dennis Bock <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 322 East Harney Lane 425 313-8100 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Lodi CA 95240 1 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Costco Wholesale Dennis Bock <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 999 Lake Drive 425 313-8100 <br /> CITY M <br /> ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Issaquah I 98027 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY NIA <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2004-2007) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(200B-2016) <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=x49.00/FACILITY $ <br /> PERMANENT CLOSURE N/A <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$345/TANK #TANKS X$345= $ <br /> TEMPORARY CLOSURE N/A <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$345/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$920/FACILITY <br /> REPAIR PLAN CHECK N/A <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$345/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,mist. <br /> PIPING REPAIR FEE =S3451 FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $ 115/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $115/HOUR $ <br /> SAMPLING INSPECTION FEE = $115/HOUR $ <br /> ALL FEES ARE BASED ON THE$115 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR I j <br /> OW-71%neo roevoeen nuncrenW pdf <br />