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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMEIw,/ <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sigov.orgjehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Arco AM/PM Edgar Rizkalli <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> SEC of West Valpico Rd TBD <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> Tracy CA 95376 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Pacific West Petroleum Inc. Edgar Rizkalli <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 3400 Willow Pass Road 925 689-0557 <br /> CITYSTATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> ConcordCA 94519 Closure nstallation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2006 2007 2008 2009 2010 2011 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2006-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2011) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(a): CLOSURE FEE=$366/TANK #TANKS X$366= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$366/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANKID#(s): 1, 2A & 2B PLAN CHECK FEE=$976/FACILITY $ 976 <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE _$366/FACILITY use for piping,under-dispenser containment,ed. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR $ <br /> SAMPLING INSPECTION FEE = $122/HOUR $ <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUESTp I FACILITY ID I AMOUNT RECEIVED CHECK# 1 RECEIVED BY I DATE RECEIVED <br /> EH 23 032(REVISED 06/3/11 by KF) <br />