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910 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARIPA <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 d � � \ \�///� D <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.s'c <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />ARP Mini Mart <br />Apt 14 <br />Nick Patel <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />25775 Patterson Pass Road <br />209 835-7777 r-ly VI HUN MENTAL HEA <br />CITY <br />STATE <br />ZIP CODE <br /># OF TAN A <br />Tracy <br />CA <br />95377 <br />4 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Nick Patel <br />Karli Karns <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />39899 Balentine Avenue <br />510 477-4467 <br />CITY <br />STATE <br />I ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />ewar <br />-El <br />Closure Installation Re air etrofit <br />8180171-U1 <br />TH <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />(As of 8/1/16) $583 FACILITY FEE + $139 PER TANK <br />2011 <br />2012 <br />2013 <br />2014 <br />2015 <br />2016 <br />Facility Fee NO LONGER INCLUDES FIRST TANK <br />$ <br />PIPING REPAIR FEE = $417 / FACILITY use for piping, under -dispenser containment, ect.) <br />-El <br />MISCELLANEOUS <br />r <br />TRANSFER FEE = $ 25 Al! <br />(2011 -Aug 1, 2016) $550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />CONSULTATION FEE = $ 139/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 139 / HOUR ENVIRONMEN/ <br />L HEA <br />DEPART <br />$ <br />$130 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />CLOSURE FEE = $417 / TANK <br /># TANKS X $417 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $417 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />$ <br />TANK ID # (s) : PLAN CHECK FEE = $1112 / FACILITY <br />REPAIR PLAN CHECK Replace all dispensers with new and install new UDC adapter pans. <br />TANK ID # (s) : Dispensers/UDC's 1-2, 3-4, 5-6, 7-8 <br />$ <br />TANK RETROFIT REPAIR FEE = $417 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />417.00 <br />spill buckets, sumps, misc.) <br />$ <br />PIPING REPAIR FEE = $417 / FACILITY use for piping, under -dispenser containment, ect.) <br />-El <br />MISCELLANEOUS <br />r <br />TRANSFER FEE = $ 25 Al! <br />$ <br />CONSULTATION FEE = $ 139/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 139 / HOUR ENVIRONMEN/ <br />L HEA <br />DEPART <br />NT <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 $417.00 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY 11 DATE RECEIVED <br />Gu rt nz,) mmimGn n,7_ec_,)neat <br />9 <br />rH <br />