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A KJ 0 A 010 N <br />COUNTY <br />Greatness grows here. <br />FACILITY NAME <br />jjp�' '11111 711 �11111111�111111111 'I � III <br />r . <br />FACILITY CONTACT NAME <br />CA I I HEALTH L)"��1 I e ,I' <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 1025373-1166 <br />2016 <br />CITY STATE I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />West Sacramento CA 1 95691 <br />1 Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />UST FEES = $641 Facility Fee + $152 Per Tank <br />2012 <br />2013 <br />2014 <br />2015 <br />2016 <br />2017 <br />456.00 <br />$ <br />PIPING REPAIR FEE = $456 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />SAMPLING INSPECTION FEE = $ 152/ HOUR <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $20 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE= $456 /TANK <br /># TANKS X $456 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $456 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />$ <br />TANK ID # (s) : PLAN CHECK FEE = $1216 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />TANK RETROFIT REPAIR FEE = $456 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc.) <br />456.00 <br />$ <br />PIPING REPAIR FEE = $456 / FACILITY (use for piping, under -dispenser containment, ect.) <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 152/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 152 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 152/ HOUR <br />TCCA AKC OAxU UK I r1C A794 r1UUKLY MAI G. I IMC 1 rIA 1 CAur-cuo rCC.I I-AIU WILL DC 6ILLCU 1 U ArrLI%,AN'r.jus renalry $456.00 <br />TOTAL AMOUNT DUE 1 $ 912.00 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED <br />1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />