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SAN - o � (� UIN Environmental Health Department <br /> -- —" C O U N T Y--- - <br /> Greclness grows Dere. tom. <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Georges Mini Mart Rupi / Bikram <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE17 7F� <br /> 18662 N Hwy 88 209 914-0300 <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Lockeford CA 95237 <br /> APPLICANT BILLING NAME Elite IV Contractors APPLICANT CONTACT NAME Megan M <br /> APPLICANT MAILING ADDRESS 2535 Wigwam Dr APPLICANT PHONE # WITH AREA CODE <br /> 209 461 -6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Stockton Ca 95205 <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES = $ 550 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES = 2018 $ <br /> ( Facility+ 1st = $ 583 = $641 $961 Facility + <br /> Tank) + $130/Tank Facility + Facility + $2281Tank <br /> after list $139rTank $ 1521Tank <br /> Double Wall & 1702 $ <br /> Compliant UST <br /> FEES = $ 680 <br /> Facility + $2281Tank <br /> Tank Penally $ <br /> Assessed for <br /> Unreported Tanks <br /> ( Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE _ $201 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 = $4561 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 /> $ <br /> TANK ID # (s) : PLAN CHECK FEE = $3,040 1 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) <br /> $ <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment , cold starts , EVR upgrades , 456 . 00 <br /> Spill buckets , sumps, mise. <br /> PIPING REPAIR FEE _ $456 1 FACILITY use for piping , under-dispenser containment, etc. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $ 25 $ <br /> CONSULTATION FEE _ $ 152/ HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 1521 HOUR $ <br /> SAMPLING INSPECTION FEE _ $ 1522 HOUR $ <br /> FEES ARE BASED ON THE $152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILITY ID I AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468- 3420 F 209 464-0138 1 www.sjcehd .com <br />