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REGEIVEC) <br /> SAN JOAQUIN COUNTY NOV 18 2015 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868E.Hazelton Ave.,Stockton,CA95205-6232 D�NVIRONMENTA! <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjcehd.co <br /> q i=fllTIA nCDAOTLICAIT <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Arco AM PM Ranjeet Singh <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1340 Colony RD 599-7600 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> Ripon CA 95366 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Kim White <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr. 20 461-6337 <br /> CITY $TATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Rtnckton Closure Installation R air Retrofit <br /> ACTIVE FACILITY <br /> 2009 2010 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2011 1 2012 2013 2014 <br /> $130 PER TANK AFTER FIRST TANK $ <br /> $ <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=E35.00/FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$3901 TANK #TANKS X$390= <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$3901 FACILITY <br /> )NSTALLATION PLAN CHECK <br /> Plan Check end Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$1040/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$390/FACILITY (use formonitodrg equipment,cold starts,EVR upgrades, 390.00 <br /> spill buckets,su s,misc. <br /> PIPING REPAIR FEE=$390/FACILITY use for piping,vnder-disneer containment.ecl. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $130/HOUR $ <br /> SAMPLING INSPECTION FEE = $1301 HOUR $ <br /> FEES ARE BASED ON THE 5730 HOURLY RATE. TIME THAT EXCEEDS FEES PND WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE 1 $ 390.00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNTRECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> EN 23 032(REVISED 08-04.14) <br />