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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: wwy,sigov.or¢Iehd <br /> FACILITY NAME FACILITY .CONTACTNAME <br /> Safeway #2600 Will Kaufman <br /> FACILITY ADDRESS SITE PHONEA WITH AREA. CODE <br /> 1987 W 11th St, Tracy CA 95376 209.8 0.2950 <br /> CITY STATE ZIP CODE #.OF TANKs ,AT SITE : <br /> Tracy CA 95376 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Service Station Systems . lnc Marty Weithman <br /> APPLICANT MAILING ADDRESS APP I.CANT.PHONE #:WITH AREA CODE <br /> 680 Quinn Ave . 408- 213-6038 <br /> CITY S A E ZIP CODE CIRCLE WORK TO 13k.s DONE CONTRACTOR ICC # <br /> San Jose CA 95112 <br /> ACTIVE FACILITY <br /> 2004 2005 2006: 2007 2008 2009 <br /> $500 FEE INCLUDES FAGILITY FEE + 1 TANK (2003-2008) <br /> $550 FEE INCLUDES FAOILITY FEE + 1 TANK(2066) <br /> $ 125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE = 1$ 1 5 1 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY . IN A:CUPA PROGRAM =$24AI. FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure. in Place <br /> TANK ID # s CLOSURE. FEE. =. $3151 TANK # TAWKS.X $315 = <br /> TEMPORARY CLOSURE <br /> Plan Revtew:and Ihs ections <br /> TANK ID # (s) ; TEMPORARY CLOSURE; FEE = $315 / FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check- and Construction Ins ections <br /> TANK ID # (s) : PLAN CHECk FEE = $840:/ FA010TY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) . : <br /> TANK RETROFIT REPAIR FEE $315 F FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ 456 <br /> spill buckets sura s, misc. <br /> PIPING REPAIR ;FEE _ $3151 FACILITY (Use for pjpft, under-dispenser contal imd0ju_6ct $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = + $ <br /> :20 <br /> CONSULTATIONFEE _ $ 1051HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = 6 1051 HOUR <br /> SAMPLING INSPECTION FEE _ $ 1.051 HOUR <br /> ALL FEES ARE BASED ON THE $ 105 HOURLY RATE, TIME THAT EXCEEDS 'FEES PAD WILL BE BILLED ToAPPLICA T. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST N FACILITY ID AMOUNT RECEIVED CHECK # RECENED BY DATE RECEIVED <br /> SR <br /> EN' 23 032 (REVISED 02!23109) <br /> i <br /> 1 <br />[E <br />