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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.sicehd.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> 117717 , <br /> Gas Depot Kevin HurJ-1 <br /> FACILITY ADDRESS SITE PHONE N WITH AREA CODE 4" <br /> 1330 E Yosemite Ave L95336 <br /> 625-0332 <br /> CITY STATE pE #OF TANKS AT SITE <br /> Manteca CA <br /> LLJ <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Megan Mitchell <br /> APPLICANT MAILING ApDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr 209 1 461-6337 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Re air Retrofit <br /> ACTIVE FACILITY <br /> 2010 2011 2012 2013 2014 2015 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK <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 /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place $ <br /> TANK ID#(s): CLOSURE FEE=$390!TANK #TANKS X$390 <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins actions $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(a): PLAN CHECK FEE=$10401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK I D#(a): <br /> TANK RETROFIT REPAIR FEE =$3901 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 417.00 <br /> spill buckets,sum s,misc. <br /> PIPING REPAIR FEE=$390 t FACILITY use for I in ,under-dis enser cantairxnent ect. <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE =.$25 <br /> CONSULTATION FEE = 11301 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130/HOUR <br /> $ <br /> SAMPLING INSPECTION FEE = $1301 HOUR <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 N FACILITY ID AMOUNT RECEIVED CHECK N RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 04.22.15) <br />