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SAN JOAQUIN COUNTY LL-...+ � <br /> ENVIRONMENTAL HEALTH DEPARTMENT Z�'O <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 SEP 14 <br /> Telephone:(209)468-3420 Fa :(209)468-3433 Web:v .sicehd.com <br /> FACILITY NASAE FACILITY CONTACT NAME <br /> Arco AMPM Ranjeet Singh <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1340 Colony Rd tog 599-7600 <br /> Wry STATE LP CODE •OF TANKS AT SITE <br /> Ripon CA 95366 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Megan Mitchell <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr 20! 12L <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Irota6aDon Ir RetroM <br /> ACTIVE FACILITY <br /> 2010 2011 2012 2013 2014 2015 <br /> $550 FEE INCLUDES FACILITY FEE t t TAN( <br /> $130 PER TANG AFTER FIRST TANK $ <br /> S <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=f15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$35.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Plece $ <br /> TANK M# s : CLOSURE FEE_$3001 TANG #TANKS X$300= <br /> TEMPORARY CLOSURE <br /> Plan Re iew and Inspections) $ <br /> TANK 10 At(s): TEMPORARY CLOSURE FEE_$390!FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Constni ion Ins ecti" $ <br /> TANK ID#(s) PLAN CHECK FEE=$10401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s)'. <br /> $ <br /> TANG RETROFIT REPAIR FEE -$3901 FACILITY (um for monitoring e0uiprronl,cold starts.EVR upgrades, 417.00 <br /> —ill buckets,sum ,mix. $ <br /> PIPING REPAIR FEE=$3901 FACILITY use for ejpinII,undw-dispentitiir containment eat <br /> WSCELLANEOUS <br /> TRANSFER FEE = f 25 -- <br /> $ <br /> CONSULTATION FEE _ $130/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = 1301 HOUR _ <br /> SAMPLING INSPECTION FEE _ $130'HOUR <br /> FFES ARE BASED ON THE 130 HOURLY RATE. TNIE THAT EXCEEDS FEES PAIWILL BE BILLED APPLICMfT. <br /> TOTAL AMOUNT DUE <br /> --7$41700 <br /> OFFICE USE ONLY <br /> SERVICE REWEST# FACILITYO AYWNT gECENEO CNECK# RECENED BY OATS RECENED <br /> EH 53 OR(REVISED 045]-15) <br />