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Ir <br /> --- COUNTY <br /> -- <br /> Grca1. 11v 'sS gIo4: .s (� ko; re . <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Short Stop Food Mart Sam Hirsch <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> 20 W Turner Rd ( 209 ) 327-6171 <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Lodi CA 95240 <br /> APPLICANT BILLING NAME Elite IV Contractors APPLICANT CONTACT NAME Megan Mitchell <br /> APPLICANT MAILING ADDRESS 2535 Wigwam Dr 20P91C ) PHONE # <br /> 461 6337WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Stockton Ca 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES = $556 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES = 2018 $ <br /> (Facility+ 1st = $583 = $641 $961 Facility + <br /> Tank) + $ 130/Tank Facility + Facility + $228/Tank <br /> after 1st $ 139/Tank $152/Tank <br /> Double Wali & 1702 $ <br /> Compliant UST <br /> FEES = $680 <br /> Facility + $228ITank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE _ $20 / TANK <br /> $ <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) : CLOSURE FEE = $456 / TANK # TANKS X $456 = $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID # (s) : TEMPORARY CLOSURE FEE _ $456 / FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> $ <br /> TANK ID # (s) : PLAN CHECK FEE = $39040 / FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : <br /> $ <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, 456.00 <br /> Spill buckets, sumps , misc. <br /> $ <br /> PIPING REPAIR FEE _ $456 / FACILITY use for piping, underAis enser containment, etc. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $ 25 $ <br /> CONSULTATION FEE _ $ 1521 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 152 / HOUR $ <br /> SAMPLING INSPECTION FEE = $ 152/ HOUR $ <br /> FEES ARE BASED ON THE $152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT <br /> TOTAL AMOUNT DUE $ 456 .00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br /> 1868 E . Hazelton Avenue ( Stockton , California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd .com <br />