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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 JUL 13 2016 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.com <br /> FACILITY NAME FACILITY CONTACT NAME �•. ' J -f `u <br /> Quick Stop 138 Pargat Litt <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1153 Lincoln Way 209 835-8284 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Tragi CA 95376 <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 I ZIP CODE CIRCLE WORK TO BE DONE I CONTRACTOR[CC# <br /> OC on 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 /> e $ <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 /> $ <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 /> i <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE_$10401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$390/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $390.0 <br /> spill buckets,sumps,mise. <br /> PIPING REPAIR FEE_$390/FACILITY use for piping,under-dispenser containment,ect. $ <br /> fi <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE _ $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $130/HOUR $ <br /> SAMPLING INSPECTION FEE _ $1301 HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE.TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ 390.0 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEfVER <br /> I <br /> EH 23 032(REVISED 0422-15) <br /> k <br />