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0 <br />0 <br />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.sigov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Tower Mart #104 <br />Paul Chevalier <br />FACILITY ADDRESS <br />SITE PHONE It WITH AREA CODE <br />192 Lathrop Road <br />209 858-4998 <br />CITY STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />Lathrop CA <br />95330 <br />4 <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 <br />ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />est acramento <br />closure Installat on Re air Retrofit <br />ACTIVE FACILITY <br />TANK ID #s : CLOSURE FEE = $375 /TANK # TANKS X $375 = <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />$550 FEE INCLUDES FACILITY FEE +1 TANK (2009-2012) <br />$125 PER TANK AFTER FIRST TANK <br />2008 <br />2009 <br />2010 <br />2011 <br />201 2 <br />2013 <br />$ <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 />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID #s : CLOSURE FEE = $375 /TANK # TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (a): <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITYuse for monitoring <br />( g equipment, cold starts, EVR upgrades, <br />s ill buckets, sum s, misc.)375 <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, act.)$ <br />$ <br />MISCELLANEOUS <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 THF 5199 Unum V EnTE TIME TH T E�..«.... ....... ............ _ <br />$ <br />- -- --- - ---- _- •-• •••-•-. .....� .,,,., LnwEDS Foca PAID WILL BE BILLED W APPLICANT. <br />TOTAL AMOUNT DUE $ 375 <br />OFFICE USE ONLY _ <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 1n 6/2013 by KF) <br />