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o RECEIVED <br /> SAN JOAQUIN CouNTY MAR 10 2017 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 err d k five vL <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web.www.sicehd.com <br /> DEPARTMENT <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Flame Mini Mart Bill <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1301 W.Kettleman Lane 209 814-3581 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Lodi CA 95240 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Megan Mitchell <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr 1 209 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE I CONTRACTOR ICC# <br /> btocKton Ga yozvo ClosureInstaiation B2pgir Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2010 2011 2012 2013 2014 1 2015 <br /> $130 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 X35.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Plate <br /> TANK ID#(a): CLOSURE FEE=$390/TANK #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Pian Review and Inspections) <br /> $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Pian Check and Construction Ins ons <br /> TANK ID#(a): PLAN CHECK FEE=$1040/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$390/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 417.00 <br /> spill buckets,sumps,miser <br /> $ <br /> PIPING REPAIR FEE=$390/FACILITY use for piping,under-dispenser containment,ed. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE _ $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130/HOUR $ <br /> SAMPLING INSPECTION FEE = $130/HOUR Is <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $417.00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 0 FACILITY ID AMOUNT RECEIVED CHECK 0 I RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 04-22-15) <br /> 3 <br />