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SAN JOAQUIN COUNTY FE 2018 <br />-ENVIRONMENTAL HEALTII DEPARTMENT — -- <br />1869 F. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephare: (209) 468-3420 Fax: (209) 468-3433 Web: www,sjeehc ,I�I`�I�_�;`) i`/� €,� [lel ���••`_' 1__i ;`'; <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />N <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 />I STATE ZIP CODE I # OF TANKS AT SITE <br />Stockton <br />ICA 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 STATE <br />ZIP CODE I CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />St <br />Closure Inslailatlon Repair Retrofit <br />$ <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE= $390 ! 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 - $390 / FACILITY (use torpii Ing, under-dispen,4er containment, ect.) <br />$ <br />SAMPLING INSPECTION FEE _ $ 130/ HOUR <br />$130 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 /TANK <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= $390 ! TANK <br /># TANKS X $390 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $390 / FACILITY <br />LA <br />and Construction <br />TANK ID # (s) : I PLAN CHECK FEE = $1040 / FACIL <br />REPAIR—PLAN CHECK <br />TANK I D # (s) <br />$ <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, misc. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 1301 HOUR <br />$ <br />PIPING REPAIR FEE - $390 / FACILITY (use torpii Ing, under-dispen,4er containment, ect.) <br />$ <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE = $ 25 <br />$ <br />CONSULTATION FEE = $ 1301 HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 1301 HOUR <br />$ <br />$ <br />SAMPLING INSPECTION FEE _ $ 130/ HOUR <br />FEES ARE BASED ON THE 3130 HOURLY RATE. TIMI IHAI tXGEEDS FEES PAW Mu. BE niLLtu IU APPUGAN I. <br />TOTAL AMOUNT DUE $456.0 <br />OFFICE USE ONLY <br />SERVICE REQUEST M _J__FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 04-22-15) <br />