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SANA I � Environmental Health Delparb-nant <br /> - -- C O U N T Y Amended 6/08 /2021 Address Correction <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Super Store Industries Troy Embry <br /> FACILITY ADDRESS SITE PHONE It WITH AREA CODE <br /> 16888 McKinley Avenue ( 209 ) 858 - 3401 <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Lathrop CA 95330 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Deborah Jones <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> 2535 Wigwam Drive 209 461 - 6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Stockton CA 95330 1 Closure Installation Repair Retrofit 1 1001331 <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 + $228/Tank <br /> after 1st $139/Tank $ 152/Tank <br /> Double Wall & 1702 $ <br /> Compliant UST <br /> 7 <br /> FEES = $680 <br /> Facilit + $228/Tank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> ( Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE _ $20 1 TANK <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 /> TANK ID # ( s) : CLOSURE FEE = $456 / TANK # TANKS X $456 = $ <br /> TEMPORARY CLOSURE <br /> I <br /> Plan Review and Inspections) <br /> TANK ID # ( s) : TEMPORARY CLOSURE FEE = $4561 FACILITY $ <br /> I <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID # (s) : PLAN CHECK FEE _ $ 3 , 040 / FACILITY $ <br /> REPAIR PLAN CHECK <br /> r <br /> TANK ID # (s ) <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, cold starts , EVR upgrades , 456 <br /> Spill buckets , sumps , misc. <br /> PIPING REPAIR FEE = $456 / FACILITY use for piping , under4s enser containment, etc. <br /> { <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 $ 456 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILITY AMOUNT RECEIVED CHECK N 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 />