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SAN J OAQ U I N Environmental Health Department <br /> --COUNTY <br /> (:rconess gr-oti," lf< <br /> FACILITY NAME Count Market Place FACILITY CONTACT NAME <br /> Country Sim Grewal <br /> FACILITY ADDRESS 1789 W Charter Way SITE PHONE#WITH AREA CODE <br /> (209 ) 941-2222 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95206 <br /> APPLICANT BILLING NAME Elite IV Contractors APPLICANT CONTACT NAME Megan M <br /> APPLICANT MAILING ADDRESS 2535 Wigwam Dr APPLICANT PHONE 0 WITH AREA CODE <br /> 209 461-6337 <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+ $22arTank <br /> after 15t $139/Tank $152/Tank <br /> Double Wall&1702 $ <br /> Compliant UST <br /> FEES= $680 <br /> Facility+$228frank <br /> Tank Penalty $ <br /> Assessedfor <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE r$20 1 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): I CLOSURE FEE=$456 1 TANK #TANKS X$456= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$456 1 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ectians <br /> TANK ID#(s): PLAN CHECK FEE=$3,0401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$4561 FACILITY (use for monitoring equipment,Cold Starts,EVR upgrades, 00 <br /> Spill buckets,sumps.mist. <br /> PIPING REPAIR FEE=$456 1 FACILITY use for piping,under-dispenser containment,etc. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $1521 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION!FEE _ $1521 HOUR $ <br /> SAMPLING INSPECTION FEE = $1521 HOUR $ <br /> FEES ARE BASED ON THE 5152 HOURLY RATE,TIME THAT EXCEEDS FEES PAID WILL BE BILLED 70 APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST p FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECENED <br /> 1868 E. Hazelton Avenue I Stockton,California 95205{ T 209 468-3420 1 F 209 464-0136 I www.sjcehd.com <br />