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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTM <br />600 East Main Street, Stockton, CA 95202-30 9 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sj o�y.or /g ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />7 -Eleven #35355 <br />2-0- RoX 1025 916 7 _ 7 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />3202 West Hammer Lane <br />209 ) 9S7-21900 <br />CITY I STATE <br />ZIP CODE # OF TANKS AT SITE <br />CA <br />95209 <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />Walton Engineering, Inr. Veronica Freitas <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />2-0- RoX 1025 916 7 _ 7 <br />CITY STATE ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />West n Closure Installation FRepair)Retrofit <br />2010 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE= $375/TANK <br />2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />2011 <br />$ <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2006-2007) <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />375 <br />1 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2011) <br />$ <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY <br />$ <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 />Check and <br />TANK ID # (s) : i PLAN CHECK FEE = $1.000 / FACILITY I $ f <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />CONSULTATION FEE = $ 1251 HOUR <br />$ <br />TANK RETROFIT REPAIR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />$ <br />spill buckets, sumps, misc. <br />$ <br />$ <br />PIPING REPAIR FEE = $375 / FACILITY use for piping, under -dispenser containment, ect. <br />375 <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 1251 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 125 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 125/ HOUR <br />$ <br />ALL FEES ARE BASED ON THE $i2b HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT DUE $ 7 <br />OFFICE USE ONLY <br />15EKVICE REQUEST # I FACILITY ID _ I AMOUNT RECEIVED I CHECK # I RECEIVED BY 1 DATE RECEIVED <br />0811111 bV <br />