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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.si o� v_ort/ehhd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Quik Stop #124 <br />Veronica Freitas <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />505 N. Main Street <br />916 373-1167 <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />Manteca CA <br />95336 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 <br />STATE I <br />ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />West Nacramento <br />CA j <br />95691 <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # s <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />$ <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 =$35.00/ FACILITY <br />$ <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 = $375 / FACILITY <br />INSTALLATION <br />(Plan Check and <br />I TANK ID # (s) : I PLAN CHECK FEE = $1000 / FACILITY I $ <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />s ill buckets, sum s, misc. <br />75 <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS <br />__ . ___ ...._ PAID <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 TUE tln. un — v o11T� r _ _ _ <br />BASED <br />$ <br />d W .�„ 11,,,,,,E 1 nN 1 G. 1 IME I nH 1 EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ 375 <br />