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OPCEIVED <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTII DEPARTMENT MAR i 3 2011/ <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Tra: (209) 468-3433 Web: www.sjgov.orLJ./eI d -AL HEALTH <br />FACILITY NAME <br />FACILITY CONTACT NAME -) ; <br />Love's Travel Stop <br />Keuth Perks <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />553 West Colony Rd <br />209 599-0704 <br />CITY <br />STATE ZIP CODE <br />�OF AT SITE <br />Ripon <br />CA 95366 <br />5 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />L.A. Perks Petroleum Specialists <br />Keuth Perks <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />765 E Greg St <br />775 358-4403 <br />CITY <br />STATE <br />I ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Reno <br />NV <br />1 89431 Closure Installation Repair Retrofit <br />8160552 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$36.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure In Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />INSTALLA <br />on <br />TANK ID # <br />PLAN CHECK FEE = $1000 / FACI <br />REPAIR PLAN CHECK <br />TANK I D # (s) : <br />$ <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $3751 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sums mist. <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />ALL FEES ARE BASED ON THE $126 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ <br />11FFI(:F !ICF ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 1/1612013 by KF) <br />N <br />