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RECEIVED <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT JAN 29 2016 <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicchd.com ENVIRnNMENLAL <br /> FACILITY NAME FACILITY CONTACT NAME NT <br /> Costco#38 Roj <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1616 E. Hammer Lane 475-9180 <br /> CITY STATE 7JP CODE #OF TANKS AT SITE <br /> Stockton CA 95205 <br /> APPLICANT BILLING NAME APPIJCANT CONTACT NAME <br /> Elite IV Contractors Kim White <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITX AREA CODE <br /> 2535 Wigwam Dr. 20 461-6337 <br /> CITY STATE LP CODE CIRCLE WORK 70 SE DONE CONTRACTOR ICC# <br /> Closure Installation Re air Retrofit <br /> ACTIVE FACILITY <br /> 2009 2010 2011 2012 2013 2014 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK $ <br /> $130 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15 1 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 /> TANK ID#(s), CLOSURE FEE=$3901 TANK #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) $ <br /> TANK ID#(a): TEMPORARY CLOSURE FEE_$31 1 FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construclian Inons $ <br /> TANK ID#(B): PLAN CHECKFEE=$1040!FACILITY <br /> REPAIR PLAN CHECK <br /> $ <br /> TANK RETROFIT REPAIR FEE =$3901 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 390,00 <br /> spill buckets,sumps,misc. $ <br /> PIPING REPAIR FEE_$3901 FACILITY use for piping,under-dispenser containment,ad. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE _ $1301 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $130/HOUR $ <br /> SAMPLING INSPECTION FEE _ $130/HOUR <br /> SEES ARE BASED ON THE=130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE S 390.0 <br /> OFFICE USE ONLY <br /> CILITY <br /> SERVICE REQUEST# FAID AMOUNT RECENED HECK RECENED BY GATE RECENED <br /> EH 23 032(REVISED 084)414) <br />