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°LTCOUNTY Ew1Ro�THEALHD ARTMENT RECEIVED <br /> 1868 E.Hazelton Ave., Stockton,CA 95205-6232 N�� 1 5 2��6 <br /> Telephone.(209)468-3420 Fax.(209)468-3433 Web:www.jcehd.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> MANTECA CHEVRON (ANNIE) GURPREE <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1490 SOUTH MAIN STREET 925 ) 785-2000 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> MANTECA CA 95337 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> MANTECA INVESTMENTS (ANNIE) GURPREET SANDHU <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1490 SOUTH MAIN STREET 925 ) 785-2000 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> MANTECA CA1 95337 Closure rnsrallatio7 Repair Retrofit T.B.D. <br /> ACTIVE FACILITY <br /> (As of 8/1116) $583 FACILITY FEE+$139 PER TANK 2011 2012 2013 2014 2015 2016 <br /> Facility Fee NO LONGER INCLUDES FIRST TANK <br /> (2011-Aug 1,2016)$550 FEE INCLUDES FACILITY FEE+1 TANK $ <br /> $130 PER TANKAFTER FIRST TANK /coo <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ 'F <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY V 3 S <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$417/TANK #TANKS X$417= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$417/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1112/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$417/FACILITY (use for monitoring equipment,cold starts, EVR upgrades, $ <br /> s ill buckets,sum s,mist. <br /> PIPING REPAIR FEE=$417/FACILITY use for piping, under-dispenser containment,act.) $. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $139/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $139/HOUR $ <br /> SAMPLING INSPECTION FEE = $139/HOUR $ <br /> FEES ARE BASED ON THE$139 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I FACILITY ID AMOUNT RECEIVED CH CK# RECEIVED BY DATE RECEIVED <br /> Skbb7G22-2 `ftZZ375-b fJ oto k Gnl;� I7,z G/S t, Ila ll� <br /> FY 911110'0=%'1Qrn M_1 S_901C1 <br />