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0 ryrr <br /> SAN JOAQUIN COUNTY 1W k-- <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 AUG 2 4 2016 <br /> Te%phare:(209)468-3420 Fav:(209)468-3433 Web:www.sicehd.conn _ <br /> EADDRESS <br /> #}— <br /> FACILITYCONTACT NAME <br /> ing Steve <br /> 2] <br /> S SITE PHONE#WITH AREA CODE <br /> t 209 466-8969 <br /> STATE ZIP CODE #OF TANKS AT SITE <br /> CA 95240 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Megan Mitchell <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr 209 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Renew Retrofit <br /> #FALITY <br /> LUDES FACILITY FEE+I TANK 2010 2011 2012 2013 2014 201NK AFTER FIRST TANKTY ASSESSED $ARGE=$15/TANK $ <br /> HARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.00/FACILITY $ <br /> PERMANENT CLOSURE <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 Ins ections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$390/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): 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 /> s ill buckets,sum s,mist. 417.00 <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 = $130/HOUR $ <br /> SAMPLING INSPECTION FEE _ $130/HOUR $ <br /> FEES ARE BASED ON T5E;130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED To APPLICANT. <br /> TOTAL AMOUNT DUE 1 $417. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST q 1 FACILITY ID AMOUNT RECEIVED CHECK q I RECEIVED BY I DATE RECEIVED <br /> EH 23 032(REVI5ED 0422.15) <br />