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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205 6232 <br />Teleplrarc: (209) 468-3420 Fax: (209) 468-3433 WeG: www.s'c R <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />ARP Mini Mart <br />Nick Patel <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />25775 Patterson Pass Road <br />-. .(I 11 f\Jlnl-III ,1L <br />209 835-7777 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TAN ki All T <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 <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />NewarK <br />UA <br />I 94bbU <br />Closure Installation Repair Oetrofit <br />8180171-U1 <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 />CN 1- <br />Facility Fee NO LONGER INCLUDES FIRST TANK <br />(2011 -Aug 1, 2016) $550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />$130 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <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 />F # 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 />TANK RETROFIT REPAIR FEE = $417 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, 417.00 <br />spill buckets, sumps, misc. <br />PIPING REPAIR FEE = $417 / FACILITY (use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />,Fl <br />TRANSFER FEE _ $ 25 <br />APH <br />$ <br />CONSULTATION FEE _ $ 139/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 139 / HOUR ENVIRONMEN <br />AL HEAL <br />DEPART <br />CN 1- <br />SAMPLING INSPECTION FEE = $ 139/ HOUR <br />FttS AKt t3AJtU VN IN ylJU NVUKLT KAI t. IIIVIC INAI CAI.CGUa r CCa rHIV VVILL 0C DILLLV Iv -F-11 I. <br />TOTAL AMOUNT DUE $417.00 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />PW 91 x117 iPP%IICFf1 r17-AS:_')A4r'1 <br />III <br />