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- SAN JOAQUIN COUNTY RECEIVED ENVIRONMENTAL HEALTH DEPARTMENT 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 FEB 11 2016 Telephone:(209)468-3420 Far:(209)468-3433 Web:www sicchd.com FACILITY NAME FACILITY CONTACT NAME IY 1 AL Arch Arco AM PM Gill or Nerria ugBlTw r)MI RTMENT FACILITY ADDRESS SITE PHONE#WITH AREA CODE 4855 S. Hwy 99 East Frontage Rd 948-2438 CITY STATE ZIP CODE ---T#—OF TANKS AT SITE Stockton CA 95215 APPLICANT BILLING NAME APPLICANT CONTACT NAME Elite IV Contractors >00n AA74W Terry Masters APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE 2535 Wigwam Dr. 1 20 461-6337 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Closure Installation Repair Relroo[ ACTIVE FACILITY 2009 2010 2011 2012 2013 2014 $550 FEE INCLUDES FACILITY FEE+1 TANK $130 PER TANK AFTER FIRST TANK $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE=$15 1 TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY PERMANENTCLOSURE Removal or Permitted Closure In Place TANK ID# s CLOSURE FEE=$390!TANK #TANKS K$390= TEMPORARY CLOSURE Plan Review and Inspections) $ TANK 10#(a): TEMPORARY CLOSURE FEE=$390/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) $ TANK ID#(s): PLAN CHECK FEE=$1040!FACILITY REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$390/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 390.00 .� sill buckets,Sumps,mise $ PIPING REPAIR FEE=$390/FACILITY use for piping,under-dispenser containment,Oct. MISCELLANEOUS 1 TRANSFER FEE _ $25 CONSULTATION FEE _ $1301 HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $130/HOUR $ SAMPLING INSPECTION FEE _ $1301 HOUR FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT MUM FEES PAID WILL BE BILLED TO APPLICANT. TOTAL AMOUNT DUE $ D OFFICE USE ONLY SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED EH 23 032(REVISED 0"e 14)