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SAN JOAQUIIN COUNTY FEB 0 4 2016 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 �p�M'ENTAL <br /> Telephone:(209)468-3420 Fay:(209)468-3433 Web:wn .sicehd.com ENVIRQN •�T1NT <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Woodbridge Arco Jazz <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 18970 Lower Sacramento 339-8238 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Woodbrige CA 95258 <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 /> CITYSTATE ZIP CODE CIRCLE WORKTO BE DONE CONTRACTOR ICC# <br /> Closure Installation RepIT Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+i TANK 2009 2010 2011 2012 2013 1 2014 <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=$35.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID#(a): CLOSURE FEE=$390/TANK #TANKS X$300= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$390/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#ts).. PLAN CHECK FEE=$1040/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$390/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc.)`�90•0� <br /> PIPING REPAIR FEE_$390/FACILITY use for pipirig,under-dispenser containment,ed. $ <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$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ 390.0 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACWTYIO I AMOUNT RECEIVED I CHECKO I RECEIVED BY I DATE RECEIVED <br /> EH 23 032(REVISED 06-04.14) <br />