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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sicelid.com <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Waterloo Food Mart <br />Rupi Padda <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />4315 Watreloo Rd <br />209- 31-3674 <br />CITY <br />STATE ZIP CODE <br /># OF TANKS AT SITE <br />Stockton <br />I CA 95216 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Elite IV Contractors <br />Megan <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 DONECONTRACTOR <br />ICC # <br />Stockton <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK I D # (s): <br />CLOSURE FEE = $390 / TANK # TANKS X $390 = <br />2010 <br />2011 <br />2012 <br />2013 <br />2014 <br />2015 <br />456.00 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY use for piping, under -dispenser containment, act. <br />$130 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <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 I D # (s): <br />CLOSURE FEE = $390 / TANK # TANKS X $390 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $390 / FACILITY <br />4LLATION PLAN CHECK <br />Check and Construction Ir <br />W20 4UF3 <br />PLAN CHECK FEE = $1040 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />CONSULTATION FEE = $ 130/ HOUR <br />$ <br />TANK RETROFIT REPAIR FEE = $390 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc.) <br />456.00 <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY use for piping, under -dispenser containment, act. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 130/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 130/ HOUR <br />$ <br />Feta ARE 5AJeu ON THE 030 HOURLY RA Iz. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE 1$456.001 <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 />