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RECEIVED <br />SAN JOAQUIN COUNTY FEB G 7 2018 <br />ENVIRONMENTAL HEAL-TH-DEPARTMENT — <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Far: (209) 468-3433 W'eb: www.sjcehd.Com_NVIRONMENTAL HEALTH <br />a, NT <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Waterloo Shell <br />Ru i Padda <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />4315 E Waterloo Rd <br />209 914-8735 <br />CITY <br />STATE ZIP CODE # OF TANKS AT SITE <br />Stockton <br />I CA 95205 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Elite IV Contractors <br />Megan Mitchell <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 Wigwam Dr <br />209 461-6337 <br />CITY <br />STATE <br />I ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />PIPING REPAIR FEE = $3901 FACILITY use for piping, under -dispenser containment, ect. <br />Closure Installation Repair Retrofit <br />$ <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE _ $3901 TANK <br />2010 <br />2011 <br />2012 <br />2013 <br />2014 <br />2015 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />PIPING REPAIR FEE = $3901 FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />SAMPLING INSPECTION FEE _ $ 1301 HOUR <br />$130 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE _ $15 / TANK <br />_ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.001 FACILITY <br />PERMANENT CLOSURE <br />(Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE _ $3901 TANK <br /># TANKS X $390 = <br />TEMPORARY CLOSURE <br />Plan Review and inspections) <br />TANK ID #(s) : <br />TEMPORARY CLOSURE FEE = $390 / FACILITY <br />ION PLAN CHECF <br />and Construction I <br />TANK ID # <br />PLAN CHECK FEE = $10401 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) <br />$ <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $390 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />456.00 <br />spill buckets, sumps, mist. <br />$ <br />PIPING REPAIR FEE = $3901 FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 1301 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 1301 HOUR <br />FEES ARE BASED ON THE $130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID wiLL BE BILLED TO ArrucAN i. <br />TOTAL AMOUNT DUE $456.0 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 04-22-15) <br />