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SAN �JOAQUIN Environmental <br /> COU NTY REh@efVeD <br /> Greotness grows ilei 10! 0 2 2013 <br /> FACILITY NAME FACILITY CONTACT NAME <br /> P Mini Mart Nick Patel <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE EALTH <br /> 25775 Patterson Pass Road 209 835-7777 '-� _r-" T <br /> CITY STATE ZIP CODE #OF TANKS AT S <br /> Tracy CA 95377 4 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> National a ro eum Nick Patel <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 39899 Balentine Drive, Suite 370 <br /> CITY I STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Newark Closure Installation Repair Retr fit <br /> ACTIVE FACILITY <br /> UST FEES= $641 Facility Fee+$152 Per Tank 2012 2013 2014 2015 2016 2017 <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$20/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$456/TANK #TANKS X$456= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$456/FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1216/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$456/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 456.00 <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE=$456/FACILITY (use for piping,under-dispenser containment,ect.) $456.00 <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $152/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $152/HOUR $ <br /> SAMPLING INSPECTION FEE = $152/HOUR $ <br /> FEES ARE BASED ON THE$152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE 1 $ 912.00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> 1868 E. Hazelton Avenue I Stockton, California 952051 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />