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f ID <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT JUN 0 7 2017 <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone. (209)468-3420 Faz:(209)468-3433 Web:www.s'cehd.com _1LTI"I <br /> VIRONM HEALTH <br /> FACILITY NAME =FACILITYONTACT NAMEJahant Food & Fugh <br /> FACILITY ADDRESSE#WITH AREA CODE2432 N Highway 927-2863 <br /> CITY #OF TANKS AT SITE <br /> Acam o <br /> APPLICANT BILLINGNAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Megan Mitchell <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr 209 1 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> OC OnI Ga I U5205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2010 2011 2012 2013 2014 2015 <br /> $130 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID# s : CLOSURE FEE=$390/TANK #TANKS X$390= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$390/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> PLAN CHECK FEE_$1040/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$390/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,misc.) 625.50 <br /> PIPING REPAIR FEE=$390/FACILITY use for piping,under-dispenser containment,act. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1301 HOUR $ <br /> SAMPLING INSPECTION FEE = $130/HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE 1 $625.501 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST li FACILITY ID I AMOUNT RECEIVED I CHECK# I RECEIVED—BY1 DATE RECEIVED <br /> EH 23 032(REVISED 04.2245) <br />