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°"pDI"c�, SAN�►1 QUIN <br />j <br />�. <br />COUNTY— <br />Greatness grows here. <br />Environntal Health Department <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Anabi Oil - Shell <br />Scott Willett <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2375 West Grant Lin <br />760 722 - 9002 <br />CITY <br />I STATE ZIP CODE <br />I # OF TANKS AT SITE <br />Tracy <br />CA 195377 <br />4 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />DiMacido Maintenance Inc. <br />cot_ I ett <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2603 IndustU Street <br />760 722 - 9002 <br />CITY <br />I STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONECONTRACTOR <br />ICC # <br />Oceanside <br />ICA <br />1 92054 <br />1 Closure Installation Repair Retrofit <br />18405822 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $456 / TANK <br />UST FEES = $641 Facility Fee + $152 Per Tank <br />2012 <br />2013 <br />2014 <br />2015 <br />2016 <br />2017 <br />$ <br />$ 456 <br />PIPING REPAIR FEE = $456 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />0 <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 152 / HOUR <br />$0 <br />$ <br />TANK PENALTY ASSESSED <br />SAMPLING INSPECTION FEE = $ 152/ HOUR <br />$ <br />0 <br />TANK SURCHARGE = $20 / TANK <br />0 <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />0 <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $456 / TANK <br /># TANKS X $456 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $456 / FACILITY <br />INSTALLATION PLAN CHECi <br />(Plan Check and Construction I <br />TANK ID # (s) : I PLAN CHECK FEE _ $1216 /FACILITY 1$ 0 <br />REPAIR PLAN CHECK <br />TANK ID#(s): <br />$ <br />$ <br />TANK RETROFIT REPAIR FEE = $456 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />456 <br />spill buckets, sumps, misc. <br />CONSULTATION FEE = $ 152/ HOUR <br />$ <br />$ 456 <br />PIPING REPAIR FEE = $456 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />$ <br />0 <br />TRANSFER FEE _ $ 25 <br />CONSULTATION FEE = $ 152/ HOUR <br />$ <br />0 <br />$ <br />0 <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 152 / HOUR <br />$ <br />0 <br />SAMPLING INSPECTION FEE = $ 152/ HOUR <br />FEES ARE BASED ON THE $152 HOURLY KA rE. I IME ]HAI EALEEUS FEE5 YAIU WILL Bt BILLLU IU Ar YLIUAN I. <br />TOTAL AMOUNT DUE $ 912 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />