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• fir. p <br /> • L <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT APR 2 9 2016 <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sicehd.corl , <br /> FACILITY NAME FACILITY CONTACT NAME ;- <br /> Fast&Easy Mart-Chevron Morada Bill <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 10878 N. HWY 99 931-6154 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95212 <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. 1 20 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2009 2010 2011 2012 2013 2014 <br /> $130 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15 1 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$35.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(a): CLOSURE FEE=$390/TANK #TANKS X$390= $ <br /> TEMPORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$390/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK to#(s): PLAN CHECK FEE=$1040/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE _$390/FACILITY (use for monitoring equipment,mid starts,EVR upgrades, 390,00 <br /> spill buckets,sumps,mist. <br /> PIPING REPAIR FEE_$3901 FACILITY use for piping,under-dispenser containment,act.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1301 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 $390.00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID I AMOUNT RECENED CHECK# I RECEIVED BY I DATE RECEIVED <br /> EH 23 032(REVISED 08-04.14) <br />