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• • SAN JOAQUIN COUNTY ENVIRONMENTAL TIEALTH DEPARTMENT 1868 E. Hazelton Ave., Stockton, CA 95205-6232 Telephone, (209) 468-3420 Far: (209) 468-3433 Web. www.sicehd.com MAR 01 2016 ENVIRONMENTAL FACILITY NAME FACILITY CONTACT NAME Costco #1031 Manager FACILITY ADDRESS SITE PHONE # WITH AREA CODE 2440 Daniels St 209 824.2860 CITY STATE IIP CODE # OF TANKS AT SITE Manteca CA 95336 APPLICANT BILLING NAME APPLICANT CONTACT NAME Elite IV Contractors Megan Mitchell APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2535 Wigwam Df 2� 09 1461-6337 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICG # OC Oil Closure Installation Re air Retrofit ACTIVE FACILITY TANK I D # s CLOSURE FEE = $390 / TANK 2010 2011 2012 2013 2014 2015 $ $550 FEE INCLUDES FACILITY FEE + 1 TANK $130 PER TANK, AFTER FIRST TANK $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $151 TANK $ STATE SURCHARGE FOR FACILITIFS NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =535.00/ FACILITY PERMANENTCLOSURE Removal or Permitted Closure in Place TANK I D # s CLOSURE FEE = $390 / TANK # TANKS X $390 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID tar {s) : TEMPORARY CLOSURE FEE = $39101 FACILITY kLLATION PLAN CHEC Check and Construction TANK ID It (r): PLAN CHECK FEE = $1040 1 FACI LITY REPAIR PLAN CHECK TANK ID #(s) : $ TANK RETROFIT REPAIR FEE = $390 1 FACILITY (use for monitoring equipment, cold starts, EVR upgrades, spill buckets, sumps, m1sc. $ 390.00 PIPING REPAIR FEE = $3901 FACILITY use far piping, under -dispenser containment, ect. $ MISCELLANEOUS TRANSFER FEE _ $ 25 $ CONSULTATION FEE = S 1301 HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE = S 1301 HOUR $ SAMPLING INSPECTION FEE = S 1301 HOUR $ FEES ARE BASED ON THE $130 HOURLY RATE. TIME THAT EXCEEDS FEES PA1D WILL BE BILLED TO APPLICANT, TOTAL AMOUNT DUE 1$390.00 OFFICE USE ONLY SERVICE R€QUEST# FACIL9TY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED EH 23 032 (REVISED 0422-15)