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" ' rE SAN jOA0 U I N Environmental Health Department <br /> s COUNTY --- <br /> " ` Circ atness yIc; whe � v <br /> FACILITY NAME FACILITY CONTACT NAME <br /> o onia neray SITE PHONE # WITH AREA CODE <br /> FACILITY ADDRESS <br /> CITY <br /> 14000 E . HW STATE ZIP CODE <br /> 8H # OF TANKS AT SITE <br /> Lockeford CA 1 95237 3 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> a ton En ineerin , lnc . Veronica Freitas <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> s P . O . BoxK TO BE DONE <br /> 1025 <br /> CITY STATE ZIP CODE CIRCLE WORCONTRACTOR ICC # <br /> i' CA 95691 Closure Installation Repair Retrofit <br /> West Sacramento <br /> i <br />` ACTIVE FACILITY <br /> UST FEES = $641 Facility Fee + $ 152 Per Tank 2012 2013 2014 2015 2016 2017 <br /> TANK PENALTY ASSESSED <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 Ins ections $ <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 _ $ 1216 / FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, cold starts , EVR upgrades, <br /> 456 <br /> spill buckets , sum s , misc. $ <br /> PIPING REPAIR FEE = $456 / FACILITY use for i ing , underAis enser containment, ect. <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 Includin an extra $ 456 . 00 for late ermit $ 912 <br /> OFFICE USE ONLY I RECEIVED BY DATE RECEIVED <br /> SERVICE REQUEST # I FACILITY ID AMOUNT RECEIVED CHECK # <br /> 1868 E . Hazelton Avenue Stockton , California 952051 T 20946 & 34201 F 209464-0138 I www . sjcehd . com <br />