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SAN 10 A Q U I N Environmental Health Department <br /> --COUNTY <br /> Uicotness grows hr.r(-. <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Arco am/pm Ru inder Pada <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 14931 N Flag City Blvd (209 ) 366-1414 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Lodi CA 95242 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Deborah Jones <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Drive 209 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Stockton CA 95205 1 Closure Installation Repair Retrofit 1001331 <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)+$130rrank Facility+ Facility+ $228/Tank <br /> after 1st $139rrank $152/Tank <br /> Double Wall&1702 $ <br /> Compliant UST <br /> FEES= $680 <br /> Facility+$228/Tank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE_$20/TANK <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=$3,040/FACILITY $1 00 <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <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,etc. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $152/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 $100 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> 1866 E. Hazelton Avenue I Stockton,California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />