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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.sicehd.com <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Tower Mart #104 <br />Veronica Freitas <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />192 Lathrop Road <br />916 373-1166 <br />qry <br />STATE ZIP CODE <br />I # OF TANKS AT SITE <br />Lathrop <br />CA 95330 <br />1 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 />916 373-1166 <br />CITY <br />STATE <br />I ZIP CODE CIRCLE WORKTO DONE CONTRACTOR ICC # <br />—West Sacramento <br />I CA <br />lla <br />1 95691 Closure Instation Re air Retrofit <br />ACTIVE FACILITY <br />TANK ID# (s): <br />CLOSURE FEE = $390 / TANK <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />2014 <br />390 <br />$550 FEE INCLUDES FACILITY FEE+ 1 TANK <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY use for piping, under -dispenser containment, ed. <br />1 <br />$130 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE =$15/TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY <br />PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID# (s): <br />CLOSURE FEE = $390 / TANK <br /># TANKS X$390= <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (a): <br />TEMPORARY CLOSURE FEE = $390 / FACILITY <br />Check <br />TANK ID # (a): I PLAN CHECK FEE = $10401 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) <br />$ <br />CONSULTATION FEE = $ 130/ HOUR <br />$ <br />TANK RETROFIT REPAIR FEE = $390 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc.) <br />390 <br />SAMPLING INSPECTION FEE = $ 130/ HOUR <br />$ <br />PIPING REPAIR FEE = $390 / FACILITY use for piping, under -dispenser containment, ed. <br />MISCELLANEOUS <br />TRANSFER FEE =$25 <br />$ <br />CONSULTATION FEE = $ 130/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 130/ HOUR <br />$ <br />FEES ARE BASED ON THE $130 HOURLY RATE. TIME THAT EXCtEo5 Ftts rnlu wiLL nt BiLLED TO AFFUCAN i. <br />TOTAL AMOUNT DUE 1 $ 390 <br />OFFICE USE ONLY <br />SERVICE REQUEST # I FACILITY ID I AMOUNT RECEIVED I CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 08-04-14) <br />