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Environmental Health <br /> SAN 10 A Q U t N <br /> - COUI\JTY- - - <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Country Side Mini MArt Rupi Padda <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> 14971 N Hwy 88 ( 209 ) 914-8735 <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 APPLICANT PHONE # WITH AREA CODE <br /> 209 461 .6337 <br /> CITY Stockton STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Ca 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES = $ 550 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES = 2018 $ <br /> ( Facility+ 1st = $ 583 = $641 $961 Facility + <br /> Tank) + $1301Tank Facility + Facility + $228/Tank <br /> after 1st $ 1391Tank $152lTank <br /> Double Wall & 1702 $ <br /> Compliant UST <br /> FEES = $680 <br /> Facility + $2281Tank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <br /> $ i <br /> TANK SURCHARGE _ $20 1 TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.001 FACILITY <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place <br /> $ <br /> TANK ID # (s) : CLOSURE FEE = $456 / TAN # TANKS X $456 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID If (s) : TEMPORARY CLOSURE FEE _ $456 / FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins eCtIons <br /> $ <br /> TANK ID # (s) : PLAN CHECK FEE _ $3 ,0401 FACILITY <br /> i <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 /> I <br /> Spill buckets, sumps , misc. <br /> PIPING REPAIR FEE _ $456 ! FACILITY use for piping, under-dispenser containment, etc. I lip <br /> MISCELLANEOUS <br /> $ <br /> TRANSFER FEE _ $ 25 <br /> CONSULTATION FEE _ $ 1521 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 152 ! HOUR $ <br /> SAMPLING INSPECTION FEE _ $ 1521 HOUR $ <br /> FEES ARE BASED ON THE 5152 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 5 FACILITY ID AMOUNT RECEIVED CHECK ti RECEIVED BY DATE RECEIVED <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 1 F 209464-0138 1 www. sicehd . com <br />