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W <br /> P 'p <br /> SAN JO Q Po <br /> ENVIRONMENTAL HEALTH DEPARTMENT JUL 18 2017 <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicchd.com <br /> r n <br /> FACILITY NAME FACILITY CONTACT NAME '— ' .I,7'A.L HSALT <br /> US Gas Johnny DEPAR. l%'s <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 749 E Dr. Marten Luther King Blvd j2 9 4 5-897 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95206 <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 209 461-6337 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Stockton Ca Closure Installation Repair Retrofit IF <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+I TANK 2010 2011 2012 2013 2014 2015 <br /> $130 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM X35.001 FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s : CLOSURE FEE=$390/TANK #TANKS X$390= $ <br /> TEM PORARYCLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$390/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ons <br /> TANK ID fla):: PLAN CHECK FEE=$10401 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$3901 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 684.00 <br /> spill buckets,sumps,misc, <br /> PIPING REPAIR FEE=$390/FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = 1301 HOUR $ <br /> SAMPLING INSPECTION FEE = $1301 HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE 1 $684.001 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 04-22-15) <br />