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WVL <br /> SAN JOAQUIN COUNT!' MAR 3 0 2016 <br /> ENVIRONMENTAI.,HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 FtLv:(209)468-3433 Web:www.siechcl.com ENVIRONMENTAL <br /> 1-ICAITIJ nr..�w raTnAGIUT <br /> i <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Waterloo Shell Rupi Padda <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 4315 E. Waterloo Rd 209 931-3674 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton ICA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Carrie Miller <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr. 209 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2009 2010 2011 2012 2013 2014 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK <br /> $130 PER TANK AFTER FIRST TANK $ ?y <br /> 1 <br /> $ 9 <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK $ <br /> i <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.001 FACILITY $ I <br /> I <br /> PERMANENT CLOSURE i <br /> Removal or Permitted Closure in Place { <br /> TANK ID#(s): CLOSURE FEE=$3901 TANK #TANKS X$390= $ I <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections <br /> $ E <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$390/FACILITY j <br /> i <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1040/FACILITY $ <br /> REPAIR PLAN CHECK <br /> i <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$390/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,mist.) 390.00 <br /> PIPING REPAIR FEE=$390/FACILITY use for piping,under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $1301 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130/HOUR $ <br /> SAMPLING INSPECTION FEE = $130/HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE Adding in fee's to expited permit $ 585.0 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 08.04.14) <br />