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C <br />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.sicehd.com AUG n, 2 2nifi <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Flag City Shell <br />Rupi Padda ENVIRONMENTAL <br />PER <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE 1111�A:tWIGES <br />6437 Banner St <br />209 914-8735 <br />CITY <br />STATE ZIP CODE # OF TANKS AT SITE <br />Lodi <br />ICA 95242 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Elite IV Contractors <br />Megan Mitchell <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 Wigwam Dr <br />209 461-6337 <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />SMckton I Qa <br />Closure Installation Repair Retrofit <br />m <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $390 / TANK <br />2010 <br />2011 <br />2012 <br />2013 <br />2014 <br />2015 <br />$ <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />PIPING REPAIR FEE = $390 / FACILITY use for piping, under -dispenser containment, act. <br />1 <br />$130 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TANK PENALTY ASSESSED <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 ID # (s): <br />CLOSURE FEE = $390 / TANK <br /># TANKS X $390 = <br />TEMPORARY CLOSURE <br />Pian Review and Inspections) <br />TANK ID # (s) : <br />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 # (s) : <br />$ <br />CONSULTATION FEE = $ 130/ HOUR <br />$ 417.0 <br />TANK RETROFIT REPAIR FEE = $390 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />s ill buckets, sumps, misc. <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 />FEES ARE BASED ON THE $730 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ 417.0 <br />OFFICE USE ONLY <br />