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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Haze1ton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www,sicchd.corn <br />tV <br />JUN (). 2 2017 <br />FACILITY NAME FACILITY CONTACT NAME : <br />Short Stop Sam Hirsch <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />20 W Turner Rd (559 ) 366-0699 <br />CITY STATE ZIP CODE # OF TANKS AT SITE <br />Lodi CA 95260 <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 t. CONTRACTOR ICC # <br />Stnnktnn Ga 9520b Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$130 PER TANK AFTER FIRST TANK <br />2010 2011 2012 2013 2014 2015 <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE 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 = $no i TANK # TANKS X $390 = $ <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : TEMPORARY CLOSURE FEE = $390 / FACILITY <br />$ <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 = $390 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />spill buckets, sumps, misc.) <br />$ <br />417.00 <br />PIPING REPAIR FEE = $390 / FACILITY (use for piping. under-dispenser containment, ect.) <br />$ <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 />NA • IT <br />$ <br />FEES ARE BASED ON THE . <br />TOTAL AMOUNT DUE $ 417.00 <br />OFFICE USE ONLY <br />SERVICE REQUEST II FACILITY ID AMOUNT RECEIVED CHECK RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 04-22 15)