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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 Fax: (209 ) 468-3433 Web: www.sigov. org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Kwik Sery Lodi Monica Farhat <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> 420 W Kettleman Lane , Lodi CA 95240 09-319-2790 <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Lodi CA 95240 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 ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> San Jose CA 95112 <br /> • <br /> ACTIVE FACILITY <br /> ' <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 /> 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, $ 456 <br /> spill buckets, sum s, misc. <br /> PIPING REPAIR FEE _ $315 / FACILITYuse for i in , under-dlspenser containment, ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $ 20 <br /> te CONSULTATION FEE _ $ 105/ HOURUNAUTHORIZED RELEASE EVALUATION FEE = $ 105 / HOUR <br /> SAMPLING INSPECTION FEE _ $ 105/ HOUR $ <br /> ALL FEES ARE BASED ON THE 5105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT, <br /> OFFICE USE ONLY <br /> SERVICE REOUESTII I FACILITY ID I AMOUNT RECEIVED CHECK # I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032 (REVISED 02123109) <br /> i <br /> i <br /> i <br /> I <br /> I <br />