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$AW.JOAQUIN Environmental Health Department <br /> L COUNTY <br /> s ` Greatness grows here. <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Arco am/pm Manteca Sarvjit Singh <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 2010 Crestwood Avenue 209 740-5500 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Manteca CA 95336 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ASP Petroleum Sarvjit Singh <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 3819 scena Court 209 740-5500 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> urlock CA 95382 Closure nstallation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES= $641 Facility Fee+$152 Per Tank 2012 2013 2014 2015 2016 2017 <br /> $ 1,0 <br /> 97 <br /> $ 1 <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$20/TANK $ 60 <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 /> TANK ID#(s): TEMPORARY CLOSURE FEE=$456/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1216/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$456/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spill buckets,sumps,misc. <br /> PIPING REPAIR FEE=$456/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 <br /> CONSULTATION FEE _ $152/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $152/HOUR t 1 1) 3 1? <br /> AN JUIN <br /> SAMPLING INSPECTION FEE _ $ 152/HOUR ENX Cot rIY7-V <br /> FEES ARE BASED ON THE$152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. LTH D N]AL <br /> TOTAL AMOUNT DUE $2,4 NT <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> /a-o - -44.a4 S 7 "510 /'7 <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-34201 F 209 464-0138 1 www.sjcehd.com <br />