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SAN JOAQUIN COUNTY ` <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 DIC 0 7 2016 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: www.sicehd.com <br />FACMT NAME— <br />CT NfAME <br />�ACfLITY CONTA777 <br />Pilot Travel Centers LLC <br />DEPk--.7 IMEN <br />FACILITY ADDRESS <br />1501 N. Jack Tone Road <br />SITE PHONE # WITH AREA CODE <br />209 599-4141 <br />CITY <br />STATE ZIP CODE <br /># OF TANKS AT SITE <br />Ripon <br />CA 95366 <br />6 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Jones Covey Group, Inc. <br />Steve Sills <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />9595 Lucas Ranch Road #1100 Rancho Cucamonga, CA 91730 <br />909 972-7581 <br />CITY <br />CITY <br />STATE ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />Closure lnstaliat Re r trofrt <br />002 452 <br />m-l7vc rmwul 7 - - -- <br />TANK 1D # (s): CLOSURE FEE = $417 !TANK # TANKS X $417 = <br />(As of 811118) $583 FACILITY FEE + $139 PER TANK <br />Facility Fee NO LONGER INCLUDES FIRST TANK <br />(2011 -Aug 1, 2016) $550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$130 PER TANK AFTER FIRST TANK <br />2011 <br />1 2012 <br />2013 <br />2014 <br />2015 <br />2016 <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.001 FACILITY Is <br />PERMANENT CLOSURE <br />Removal or Permitted Closure In Place <br />TANK 1D # (s): CLOSURE FEE = $417 !TANK # TANKS X $417 = <br />TEMPORARY CLOSURE <br />Pian Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $417 / FACILITY <br />Check and <br />I TANK ID # (s) : i PLAN CHECK FEE= $1112 /FACILITY I �1) I <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $417 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ 417 <br />s 111 buckets, sumps, mise) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $139 / HOUR <br />PIPING REPAIR FEE = $417 / FACILITY use for piping, under -dispenser containment, ect. <br />$ <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 = $ 1391 HOUR <br />PEES ARE BASED ON THE $139 HOURLY RATE TIME THAT EX <br />$ <br />CEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ 417 <br />OFFICE USE ONLY <br />