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SAN J O A Q U I N Environmental Health Department <br /> - - - COU NTY - <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Speedway #4612 <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> 2448 West Kettleman Lane ( ) <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Lodi CA 95242 2 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Walton Engineering , Inc. Sarah Jablonsk <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> PO Box 1025 916 373- 1165 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Sacramento CA 95691 Closure Installation—< ai Retrofit 8712762 <br /> ACTIVE FACILITY <br /> UST FEES = $550 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES = 2018 $ <br /> (Facility+ 1st = $583 = $641 $961 Facility + <br /> Tank) + $130/Tank Facility + Facility + $228/Tank <br /> after 1st $139/Tank $152/Tank $ <br /> Double Wall & 1702 <br /> Compliant UST <br /> FEES = $680 <br /> Facility + $228/Tank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE _ $20 / TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID # (s) : CLOSURE FEE = $456 / TANK # TANKS X $456 = <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID # (s) : TEMPORARY CLOSURE FEE = $456 / FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID # (s) : PLAN CHECK FEE = $3 , 040 / FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment , cold starts , EVR upgrades , 456 . 00 <br /> Spill buckets , sumps , misc. <br /> PIPING REPAIR FEE = $456 / FACILITY (use for piping , under-dispenser containment, etc. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $ 25 $ <br /> CONSULTATION FEE _ $ 152/ HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 152 / HOUR $ <br /> SAMPLING INSPECTION FEE _ $ 152/ HOUR $ <br /> FEES ARE BASED ON THE $152 HOURLY RATE, TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $456 . 00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br /> 1868 E . Hazelton Avenue Stockton , California 95205 T 209 468-3420 F 209 464-0138 1 www. sjcehd . com <br />