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f <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicchd.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> L <br /> Kevin Hur r "a <br /> Gas Depot <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE 777 <br /> 1330 E Yosemite Ave 209 825-0332 <br /> CITY STATE ZIP CODE If OF TANKS AT SITE <br /> Manteca CA 95336 <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 209 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2010 2011 2 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 012 2013 2014 P015 <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=$35.001 FACILITY <br /> PERM ENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$3901 TANK #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(a): PLAN CHECK FEE=$1040/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): $ <br /> TANK RETROFIT REPAIR FEE =$3901 FACILITY (use for monitoring equipment cold starts,EVR upgrades, 417.00 <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE_$390!FACILITY use far i in ,under-dis enser crontainment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 <br /> CONSULTATION FEE _ $1301 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130/HOUR <br /> SAMPLING INSPECTION FEE = $1301 HOUR is j <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE ---F$-417.00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST#I FACILITY ID AMOUNT RECEIVED CHECK RECEIVEb BY DATE RECEIVED <br /> EH 23 032(REVISED 04-22.15) <br />