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i,kc k, atRx �y pa,. <br />SAN JOAQUIN COUNTY `r <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 N 0 V 00 ® 2016 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjcehd.com <br />� LT <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Quik StoR #39 <br />Veronica Freitas <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2285 E. Fremont Street <br />916 373-1166 <br />CITY <br />STATE ZIP CODE <br /># OF TANKS AT SITE <br />Stockton <br />I CA 95205 <br />2 <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 />916 373-1166 <br />CITY STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />West Sacramento I CA <br />1 95691 <br />Closure Installation (Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />(As of 8/1/16) $583 FACILITY FEE + $139 PER TANK <br />2011 <br />2012 <br />2013 <br />2014 <br />2015 <br />2016 <br />$ <br />Facility Fee NO LONGER INCLUDES FIRST TANK <br />$ <br />PIPING REPAIR FEE = $417 / FACILITY use for piping, under -dispenser containment, ect. <br />417 <br />1 <br />(2011 -Aug 1, 2016) $550 FEE INCLUDES FACILITY FEE+ 1 TANK <br />$ <br />$130 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE = $417 / TANK <br /># TANKS X $417 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $417 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID#(s): <br />$ <br />CONSULTATION FEE = $ 139/ HOUR <br />$ <br />TANK RETROFIT REPAIR FEE = $417 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc. <br />$ <br />$ <br />PIPING REPAIR FEE = $417 / FACILITY use for piping, under -dispenser containment, ect. <br />417 <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 139/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 139 /HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 139/ HOUR <br />$ <br />FEES ARE [BASED ON THE $139 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ 417 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 07-15-2016) <br />