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I <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone;(209)468-3420 Fax:(209)468-3433 Web:www sjgov ore/ehd <br /> FACDLITY NAME FACILITY CONTACT NAME <br /> Tracy Blvd Shell and Mini Mart Tanya Moore <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3725 N Tracy Blvd,Tracy CA 95376 209-815-7608 <br /> ET <br /> ITY STATE ZIP CODE #OF TANKS AT SITE <br /> �l <br /> racy CA 95376 <br /> 4 <br /> APPLICANT BILLING NAME APPLICANT•CONTACT NAME <br /> Service Station Systems, Inc. Marty Weithman <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 680 Quinn Ave. <br /> 408 213-6038 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR 1GC M <br /> San Jose CA 95112 0 <br /> 5258560 <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 a$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM!124.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s : CLOSURE FEE_$3151 TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Pon Chedk and Construction Ins cWns <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, $ <br /> I bockats <br /> sumps,misc. 375 <br /> PIPING REPAIR FEE _$315/FACILITY use for Piping,under-dispenser containment, <br /> MISCELLANEOUS <br /> TRANSFER FEE 20 $ <br /> CONSULTATION FEE = $105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S-105/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $10S/HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE.TIM THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# 7 FACILITY tD AMOUNT RECEIVED CHECKS RECEIVEp BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 02123!09) <br />