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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 AUG 1 <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />24 GAS & MART <br />VIRONMEN <br />. T, ^C7n�T.,, <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />1901 S. EL Dorado St. <br />( 209 ) <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />Stockton <br />I CA <br />95205 <br />CIRCLE WORK TO BE DONE <br />APPLICANT BILLING NAME <br />TANK ID # (s): <br />APPLICANT CONTACT NAME <br />Elite IV Contractors <br />2010 <br />Carrie Miller <br />APPLICANT MAILING ADDRESS <br />2013 <br />APPLICANT PHONE # WITH AREA CODE <br />2535 Wigwam Dr. <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />( 209 461-6337 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />$130 PER TANK AFTER FIRST TANK <br />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 />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />PIPING REPAIR FEE = $390 / FACILITY (use for piping, under -dispenser containment, ect.) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 130/ HOUR <br />$130 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ 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 />Check and Construction <br />IF1211211111_�)E3 <br />PLAN CHECK FEE = $1040 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $390 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />390.00 <br />spill buckets, sumps, misc. <br />CONSULTATION FEE = $ 130/ HOUR <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY (use for piping, under -dispenser containment, ect.) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 / HOUR <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 130/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 130/ HOUR <br />r CCA ARC 6Aaru um I r- 4 i.)u nuuRLT m/ 1 C. I vic I nA l CAI aauQ rmco r— vwi— — --u <br />TOTAL AMOUNT DUE $ <br />OFFICE USE ONLY <br />77QUEST# FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 08-04-14) <br />