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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 RE-Utn %j <br /> Telephone. (209)468-3420 Faw(209)468-3433 Web:www.sicelid.coi-a DEC 0 7 2016 <br /> --`F;AL^lLITYNAME - -FACILITY ONTACTWAME --- <br /> Pilot Travel Centers LLC <br /> &N V I <br /> LT <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CO E.N"TA L Hi AH <br /> 15100 N.Thornton Road 209 )339-4066 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Lodi CA 95242 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Jones Covey Group, Inc. Steve Sills <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 9595 Lucas Ranch Road#100 Rancho Cucamonga,CA 91730 909 ) 972-7581 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure lnstalfa' ear trout 1 00217 52 1 <br /> ACTIVE FACILITY <br /> (As of 8/1/16) $583 FACILITY FEE+$139 PER TANK 2011 2012 12013 2014 2015 2016 <br /> Facility Fee NO LONGER INCLUDES FIRST TANK <br /> (2011-Aug 1,20161$550 FEE INCLUDES FACILITY FEE+1 TANK <br /> $130 PER TANK AFTER FIRST TAW $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> �Removal or Permitted Closure In Place <br /> #TANKS X $ <br /> TANK ID#(s): CLOSURE FEE=$417/TANK $417 <br /> TEMPORARY CLOSURE <br /> (Plan Review and lnspectlons�__ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$417/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins egtlons) <br /> TANK ID#(s): 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 starts,EVIR upgrades, $417 <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE=$417/FACILITY use for piping,under-dispenser containment eat.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $139/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $139/HOUR $ <br /> SAMPLING INSPECTION FEE = $1391 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 REQUEST# FACILITY AMOUNT RECEIVED <br /> _ I CHECK# WED BY I DATE RECEIVED <br /> 1- <br /> cu nm nom ro�ittacn ay<t <br /> I n.4— <br />