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SAN J O A Q U I N Environmental Health Department <br /> COUNTY <br /> Greatness grows here. <br /> FACILITY NAME FACILITY CONTACT NAME <br /> C-Store w/ 76 Fuel Island Omar Nasim <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 141 E. Harney Ln. ( 916 ) 807-4076 <br /> CITY STATE ZIP CODE T#OF TANKS AT SITE <br /> Lodi CA 95240 1 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> DIN Partners. LLC. Omar Nasim <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 10840 Trinity Parkway, C-274 1 807-4076 <br /> CITY I STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Stockton I CA 1 95219 1 Closure rinstallation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES= $961 Facility Fee+$228 Per Tank 2012 2013 2014 2015 2016 2017 <br /> $1,645 ✓ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$20/TANK $ 60 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY $ 49 <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$456/TANK #TANKS X$456= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$4561 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$3,040(20 hrs.@$152 per Muniappa) $ 3,040 <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. <br /> PIPING REPAIR FEE=$456/FACILITY use for piping,under-dispenser containment,ect.) <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 $4,794 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />