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kvb ,l�-L5 SAN JOAQUTCOUNTY RECEIVED <br /> f ENVIRONMENTAL HEALTH <br /> LTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton, CA 95205-6232 NOV 1 5 Z��6 <br /> Telephone:(209)468-3420 Fax.(209)468-3433 Web:www.sicehd.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> MANTECA CHEVRON (ANNIE) GURPREE <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> BEPARTMEW- <br /> 1490 SOUTH MAIN STREET 925 785-2000 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> MANTECA CA 95337 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> MANTECA INVESTMENTS (ANNIE) GURPREET SANDHU <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1490 SOUTH MAIN STREET 925 ) 785-2000 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> MANTECA CA 95337 Closure nstallatio Re air Retrofit T.B.D. <br /> ACTIVE FACILITY <br /> (As of 8/1/16) $583 FACILITY FEE+$139 PER TANK 2011 2012 2013 2014 2015 2016 <br /> Facility Fee NO LONGER INCLUDES FIRST TANK <br /> (2011-Aug 1,2016)$550 FEE INCLUDES FACILITY FEE+1 TANK $ �OOO <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 $ 3 S <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$417/TANK #TANKS X$417= <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$417/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1112/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$417/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE=$417/FACILITY use for piping,under-dispenser containment,ed. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $139/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $139/HOUR $ <br /> SAMPLING INSPECTION FEE = $139/HOUR $ <br /> FEES ARE BASED ON THE$139 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CH CK# RECEIVED BY I DATE RECEIVED <br /> SRbb7412-2 2- I AftDA375D I /l6 hi, <br />