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SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 NOV U 12016 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.com <br /> FACILITY NAME FACILITY CONTACT NAME EALTH <br /> 7-Eleven#17334 DEPARTMENT <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 4501 N. Pershing Ave. <br /> CITYSTATE ZIP CODE #OF TANKS AT SITE <br /> Stockton CA 95207 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Walton Engineering,Inc. Veronica Freitas <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE If WITH AREA CODE <br /> P.O.Box 1025 916 373-1166 <br /> CITYSTATE ZIP CODE CIRCLE WORKT NE CONTRACTOR ICC N <br /> est acramento C 95-69--j— Closure Installation Re Ir etrolit <br /> ACTIVE FACILITY <br /> (As of 8/1/16) $583 FACILITY FEE+$139 PER TANK 2011 2012 2013 2014 2015 2016 <br /> Facility Fee NO LONGER INCLUDES FIRST TANK <br /> (2011-Aug 1,2016)$550 FEE INCLUDES FACILITY FEE+i TANK $ <br /> $130 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <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 CLOSURE FEE_$417/TANK #TANKS X$417= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$417/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(a): PLAN CHECK FEE=$1112/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$417/FACILITY (use for monitoring equipment,cold arena,EVR upgrades, 417 <br /> spill buckets,sumps,misc. <br /> $ <br /> PIPING REPAIR FEE_$417/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $139/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1391 HOUR $ <br /> SAMPLING INSPECTION FEE = $139/HOUR $ <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 REQUESTN I FACILITY ID I AMOUNT RECEIVED I CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 07-15-2016) <br />