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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT f <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sigov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />California Gas Station <br />Ted Guzman <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />1399 E. Yosemite <br />916 373-1167 <br />CITY STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />Manteca CA <br />95336 <br />3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Walton Engineering, Inc. <br />Veronica Freitas <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />P.O. Box 1025 <br />916 373-1167 <br />CITY STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />West Sacramento <br />Closure Installation Re air Retrofit <br />$ <br />ACTIVE FACILITY <br />TANK ID # s <br />CLOSURE FEE = $375 / TANK <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />375 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <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 <br />CLOSURE FEE = $375 / TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = 53751 FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />$ <br />TANK ID # (s) : I PLAN CHECK FEE = $1,0001 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc.) <br />375 <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 125/ HOUR <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ 375 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 08/1/11 by KF) <br />