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r SAN JOAQUIN COUN A ENVIRONVILNI'AI I-IFAI TH DI'.PARTMI:NI' 600 East Main Street,Stockton,CA 95202-3029 Telephone:(209)468-3420 Fnr:(209)468-3433 Weh:www.sj=off v.or;/ehd FACILITY NAME FACILITY CONTACT NAME Waterloo Shell Bill Norby FACILITY ADDRESS SITE PHONE#WITH AREA CODE 4315 Waterloo Rd 209 931-3674 CITY STATE ZIP CODE #OF TANKS AT SITE Stockton CA 95205 APPLICANT BILLING NAME APPLICANT CONTACT NAME HMC - Henderson Maintenance Company Carl Wayne Henderson APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE PO Box 31325 209 467-7573 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# Stockton CA 95213 Closure Installation Repair Retrofit 5252923-UT ACTIVE FACILITY 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2009) $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED TANK SURCHARGE=$15/TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00/FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID# s CLOSURE FEE=$315/TANK #TANKS X$315= TEMPORARY CLOSURE Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE_$315/FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID#(s): PLAN CHECK FEE_$840/FACILITY REPAIR PLAN CHECK TANK ID#(s): TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $315.00 spill buckets,sumps,misc. PIPING REPAIR FEE _$315/FACILITY (use for piping,under-dispenser containment,ect.) MISCELLANEOUS TRANSFER FEE _ $20 CONSULTATION FEE _ $105/HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $105/HOUR SAMPLING INSPECTION FEE _ $ 105/HOUR ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED SR EH 23 032(REVISED 02/23109)