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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEAL'T'H DEPA 'TME <br /> 600 East Main Street, Stockton,CA 95202-30 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.or /g ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Quik Stop #148 Debbie Markovich <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 205 W. Lockeford Street 510 445-2282 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> Lodi ICA 95240 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Same as above <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2004 2005 2006 2007 2008 2009 <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 /> 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 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 =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE _$315/FACILITY (use for piping,under-dispenser containment,ect.) $ 345 <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $105/HOUR <br /> $ <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 BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED BY DATE RECEIVED <br /> SR <br /> =w-311(1149/I�FVICFI'1(19/714/AC\ <br />