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a �1 Environmental Health Department <br /> - C CSU NTY --- <br /> FACILITY NAME FACILITY CONTACT NAME <br /> North Pole Gas 7 Food Gurvinder Singh <br /> FACILITY ADDRESS SITE PHONE it WITH AREA CODE <br /> 574 W Grantline Rd ( 209 ) 833-3416 <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Tracy CA 95376 <br /> APPLICANT BILLING NAME Elite IV Contractors APPLICANT CONTACT NAME Megan Mitchell <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> 2535 Wi wam Dr ( 209 ) 461w6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Stockton Ca 95205 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) + $1301Tank Facility + Facility + $228JTank <br /> after 1st $ 139/Tank $ 1521Tank <br /> Double Wall & 1702 $ <br /> Compliant UST <br /> FEES = $680 <br /> Facilit + $228rrank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> ( Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE = $20 [ TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49,001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID # (s) : CLOSURE FEE = $456 / TANK # TANKS X $456 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID # (s) : TEMPORARY CLOSURE FEE = $456 J FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID # (s) : PLAN CHECK FEE = $3,040 / FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, cold Starts, EVR upgrades, <br /> Spill buckets, sumps, misc. ) 52 . 00 <br /> PIPING REPAIR FEE = $456 / FACILITY use for piping , under-dispenser containment, etc. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $ 25 $ <br /> CONSULTATION FEE _ $ 152/ HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 152 / HOUR $ <br /> SAMPLING INSPECTION FEE _ $ 152/ 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 N FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED '.. <br /> t <br /> t <br /> 1868 E . Hazelton Avenue I Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd . com <br /> i <br /> I <br /> i <br />