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RECF." 'ED SAN JOAQUIN COUNTY MAy 0 5 2 01 ENVIRONMENTAL HEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton, CA 95205-6232 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicehd.com vl p n n I r. P, r- N!TA I H EALTH FACILITY NAME FACILITY CONTACT NAME ARP Mini Mart Harshad Patel FACILITY ADDRESS SITE PHONE # WITH AREA CODE 25775 Patterson Pass Road 209 835-7777 CITY STATE ZIP CODE # OF TANKS AT SITE Tracy CA 95377 4 APPLICANT BILLING NAME APPLICANT CONTACT NAME Confidence UST Services, Inc. Karli Karns APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 16250 Meacham Road 661 631-3870 CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # Bakersfield I CA 9J.5 14 Closure Installation Repair 0etrofit -)l 818017T - ACTIVE FACILITY TANK ID # (s): (As of 8/1116) $583 FACILITY FEE + $139 PER TANK 2011 2012 2013 2014 2015 2016 $ Facility Fee NO LONGER INCLUDES FIRST TANK $ 417.00 PIPING REPAIR FEE _ $417 /FACILITY use for piping,under-dispenser containment, ect. 1 (2011 -Aug 1, 2016) $550 FEE INCLUDES FACILITY FEE + 1 TANK $ $130 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $15 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $417 /TANK # TANKS X $417 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $417 / FACILITY Check and TANK ID # PLAN CHECK FEE = $1112 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ CONSULTATION FEE = $ 139/ HOUR $ TANK RETROFIT REPAIR FEE = $417 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ s ill buckets, sum s, misc. $ $ 417.00 PIPING REPAIR FEE _ $417 /FACILITY use for piping,under-dispenser containment, ect. MISCELLANEOUS TRANSFER FEE _ $ 25 $ CONSULTATION FEE = $ 139/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE _ $ 139 / HOUR $ SAMPLING INSPECTION FEE = $ 1391 HOUR $ FEES AMC BASED ON THE $139 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE $ 417.00 OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 07-15-2016)