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SAN JOAQUIN COUN'ry OCT O 4 2016 <br />ENVIRONMLNI'AL HEALTH DiTARTMENT <br />1868 F. I laielton Ave.. Stockton. CA 95205-6232 <br />Telephone: (209)-!68-3420 /--ax: (209)-468-3433 Web: \\-%vw.s-icchdreQwx <br />L-1114 IRONMENTAL HEALTH <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />West Lane Chevron <br />Rinku <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />4747 N West Lane <br />, I Lp 3) '/ <br />CITY <br />STATE ZIP CODE <br /># OF TANKS AT SITE <br />Stockton <br />CA 95210 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Elite IV Contractors <br />Kim White <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 Wigwam Dr. <br />If 209� 461-6337 <br />CITY <br />STATE <br />I ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />PIPING REPAIR FEE = $390 / FACILITY use for piping, under -dispenser containment. ect.) <br />95205 1 Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $390 /TANK <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />2014 <br />$ <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY use for piping, under -dispenser containment. ect.) <br />$130 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.001 FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place) <br />TANK ID # (s): <br />CLOSURE FEE = $390 /TANK <br /># TANKS X $390 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $390 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s), PLAN CHECK FEE = $1040 / FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />CONSULTATION FEE = $ 130/ HOUR <br />$ 417.00 <br />TANK RETROFIT REPAIR FEE _ $390 /FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc. <br />$ <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY use for piping, under -dispenser containment. ect.) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 130/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = S 130 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 130/ HOUR <br />$ <br />FEES ARE BASED GN THE >ISU HUUKL7 KA It. imiL IHAI EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE ;% �;� �(,�%' j $ 625.50 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 08-04-141 <br />