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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMEO <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjgov.or /g ehd <br />RETE VED <br />MAR ' - <br />FACILITY NAME <br />FACILITY CONTACT NAME S4W <br />7 -Eleven #35355 <br />Hirt DEP ZwF4M <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />3202 West Hammer Lane <br />( <br />CITY <br />I STATE ZIP CODE <br /># OF TANKS AT SITE <br />Stockton <br />ICA 95209 <br />Closure Installation Repair) Retrofit <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 />2011 <br />2012 <br />CITY <br />STATE I <br />ZIP CODE CIRCLE WORK TqU DONECONTRACTOR ICC # <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />Closure Installation Repair) Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE =$375/TANK <br />2008 <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />375 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2007-2008) <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009-2012) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$35.00/ FACILITY <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # (s): <br />CLOSURE FEE =$375/TANK <br /># TANKS X $375 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />$ <br />TANK ID # (s) : I PLAN CHECK FEE = $1000 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />CONSULTATION FEE = $ 125/ HOUR <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc.) <br />375 <br />PIPING REPAIR FEE = $375 / FACILITY (use for piping, under -dispenser containment, ect.) <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 />$ <br />ALL FEES ARE BASED ON THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE + 375.00 Penalty $ 750 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMPUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />%laoa! B l 3 75-6-6 1 `t77,3 <br />EH 23 032 (REVISED 1/16/2013 by KF) <br />