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0 SAN JOAQUIN COUNTY 0 FC FIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> "' <br /> 1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br /> Telephone:(209)468-3420 Frtx:(209)468-3433 Web: www.sicehd.com MAY 2 8 2015 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> H <br /> Alpha Fast Gas Jimmy I Nina Nguyen PERMITISERVI ES <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 2358 Waterloo Rd 2Q2 462-7502 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95205 <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. 20461-6337 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Re air Retrofit <br /> ACTIVE FACILITY <br /> 2009 2010 2011 2012 2013 2014 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK <br /> $130 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE_$15 1TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted C&osure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$390/TANK I #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$3901 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Ran Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1040 1 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$390 1 FACILITY (use for monitoring equipment,cold starts, EVR upgrades, 390.00 <br /> spill buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE=$390 1 FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $1301 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130 1 HOUR $ <br /> SAMPLING INSPECTION FEE = $130!HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ 390.00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 0$-04-14) <br />