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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjog v.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Arco 2093 <br />Scott Listar <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />3425 Tracy Blvd <br />209-835-1605 <br />---F—# <br />CITY <br />IP CODE <br />STATE V95376 <br />OF TANKS AT SITE <br />Trac <br />CA <br />14 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Gettler-Ryan Inc. <br />Randy Brown <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />6747 Sierra Court Suite J <br />925-551-755 or 916-826-6828 <br />CITY <br />I STATE I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />I CONTRACTOR ICC # <br />Dublin <br />ICA 194568 <br />Closure Installation Re air Retrofit <br />18057545 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />$ 375 <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />TANK ID # (s) : I PLAN CHECK FEE = $1,000 / FACILITY <br />REPAIR PLAN CHECK spill bucket Confirmation # A57046 <br />TANK ID # (s) : 87-2 & 91 tanks <br />$ <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc. <br />CONSULTATION FEE = $ 125/ HOUR <br />$ 375 <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE I $ <br />OFFICE USE ONLY <br />