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1 <br /> " XEIVED <br /> AN 1�Q� N Environmental Healtp,De�rnt <br /> COUNTY <br /> ENVIRONMENTAL_ HEA) 7y <br /> FACILITY NAME FACILITY CONTACT NAME _;ES <br /> Quik Stop Markets,#138 E.rmit Singh <br /> FACILITY ADDRESS SITE PHONE N WITH AREA CODE <br /> 1153 Lincoln Blvd. ( 209)835-6284 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Tracy CA 95376 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Deborah Janes <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Drive 209 461-6337i <br /> CITY STATE ZIP COOS CIRCLE WORK TO BE DONE CONTRACTOR ICC q <br /> Stockton CA 95205 Closure Installation Repair Retrof}t 1001331 <br /> ACTIVE FACILITY <br /> UST FEES- $550 2014 201$ UST FEES 20)6 UST FEES 20+7 VPH UST FEES= 201$ $ <br /> (Facility+isl = $583 = $641 $961 Facility+ <br /> Tank)+$138rrank Facility+ Facility $228rrank <br /> afterlst $1391Tank 5152ITank <br /> Double Wall&1702 $ <br /> Compliant UST <br /> FEES <br /> = 5660 <br /> Facial +$2281Tank <br /> Tank Penally <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <br /> 5 <br /> TANK SURCHARGE=$20/TANK S <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID#(s): CLOSURE FEE=$4561 TANK #TANKS X$456= <br /> TEMPORARYCLOSURE <br /> Plan Review and Ins ecRons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$4561 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ctians 5 <br /> TANK 10#(5): PLAN CHECK FEE=$3,0401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> $ i <br /> TANK RETROFIT REPAIR FEE =$4561 FACILITY (use formonitoring <br /> boring equipment, <br /> misc.) <br /> d starts,EVR upgrades, 456 I <br /> 5 <br /> PIPING REPAIR FEE=$4561 FACILITY use For piping,under-dls enser containmanl,etc. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE _ $1571 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 1521 HOUR <br /> SAMPLING INSPECTION FEE - 51521 HOUR <br /> FEES ARE BASED DN THE I I51 HDURLY RATE.TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TDTAL ANiOIJNT DUE $456 <br /> OFFICE USE ONLY <br /> SERVICE RE9UE57 A FACILITY ID rmou,,r RECEIVED CHECK N RECEIVBD BY GATE RECEIVED <br /> 1868 E.Hazellon Avenue i Stockton,California 95205 1 T 209 408-3420 I F 209 464-0138 1 www.sjcehd.com <br />