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, UImentalf D <br /> it <br /> COUNTY _ DEC 0 6 2017 <br /> Grcatn 5s 91 here, <br /> FACILITY NAME FACILITY CONTACT NAME LT <br /> Stop N Shop Rai - <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE ! t ,ENT <br /> 1856 Country Club Blvd 209 250-6877 _. <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95204 L�i <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Carrie Miller <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam or 209 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Stockton CA 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES= $641 Facility Fee+$152 Per Tank 2012 2013 2014 2015 2016 2017 <br /> TANK PENALTY ASSESSED <br /> $ <br /> TANK SURCHARGE=$20/TANK <br /> $ <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 /> $ <br /> TANK ID# s CLOSURE FEE=$456/TANK #TANKS X$456= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections), <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$456/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$12161 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$456/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> s ill buckets,sum s,misc.1 456.00 <br /> PIPING REPAIR FEE=$456/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $152/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $152/HOUR $ <br /> SAMPLING INSPECTION FEE = $152/HOUR $ <br /> FEES ARE BASED ON THE$152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE ` ' 1 <br /> OFFICE USE ONLY <br /> aemsee— <br /> SERVICE REQUEST it I FACILITY ID I AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED �(�• <br /> 1868 E. Hazelton Avenue I Stockton: California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com d ®t..�"1 C,V <br />