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C,� <br /> NED <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT SEP 3 0 2016 <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fav:(209)468-3433 Web:www sicchd.com EALTH <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Fremont Food Mart Joe Loa DEPAP�TME T <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 2185 Fremont St 209 937-0195 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95205 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Megan Mitchell <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 /> oc on a 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2010 2011 2012 2013 2014 2015 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK <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 CLOSURE FEE_$390/TANK #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE=$1040/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID 9(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$390 I FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 417 �5 <br /> spill buckets,sumps,mist. <br /> PIPING REPAIR FEE=$390 I FACILITY (use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 <br /> $ <br /> CONSULTATION FEE _ $130/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. J� <br /> 5 <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 04-22-15) <br />