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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT ZQ�6 <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 SEP 14 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sicchd.com <br /> FACILITY NAME FACILITY CONTACT NAME JI <br /> Arco AM PM Ranjeet Singh <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1340 Colony Rd 209 599-7600 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Ripon <br /> CA 95366 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Megan Mitchell <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Cr (20! 46'-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Dbzub losure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2010 2011 2012 2013 2014 2015 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK <br /> $130 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.001 FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID#(s): CLOSURE FEE=$390 I TANK #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections 1 $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE=$10401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> $ <br /> TANK RETROFIT REPAIR FEE _$390 I FACILITY (use for monitoring equipment,Cold starts,EVR upgrades, 417.00 <br /> III ill buckets,sum S.MISC. <br /> $ <br /> PIPING REPAIR FEE=$390 I FACILITY use for in ,underEis nser Containment,ect. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE = $25 <br /> $ <br /> CONSULTATION FEE _ $1301 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = 1130 1 HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $130/HOUR <br /> FEES AlE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $417 00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST i FACILITY ID AMOUNT RECEIVED CHECK i RECEIVED BY DATE RECENED <br /> EH 23 032(REVISED 04-22-15) <br />