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RECEIVED <br /> SAN JOAQUIN COUNTV DEC 16 2 015 <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Tekphone:(209)468-3420 Far:(209)468-3433 Web:wv,,sicehd.com ENVIRONMENTAL <br /> nco <br /> FACILITY NAME FACILITY CONTACT NAME OPP T <br /> Costco#658 Tony Haggard <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 3250 W. Grantline Rd 834-1247 <br /> CITY STATE LP CODE #OF TANKS AT SITE <br /> Tracy CA 95304 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME 19 P Y <br /> Elite IV Contractors Kim White <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE_#WITH AREA CODE <br /> 2535 Wigwam Dr. 1 2091 461-6337 <br /> CITYSTATE LP CODE CIRCLE WORK 10 BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK 2009 2010 2011 2012 2013 2014 <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 /> PERMANENT CLOSURE <br /> Removal or Permitted Closure In Place <br /> TANK ID# s CLOSURE FEE=S390/TANK #TANKS X$390= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins tions <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$390/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction I <br /> TANK ID#(s): PLAN CHECK FEE=$1040/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$390 1 FACILITYuse for monitori $ <br /> ( equipment,cdd staAs,EVR upgrades, <br /> spill buckets,sumps, <br /> mps,mist. <br /> PIPING REPAIR FEE=$390/FACILITY use for piping,under-dispenser containment act. $390.00 <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = S 1301 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1301 HOUR $ <br /> SAMPLING INSPECTION FEE _ $1301 HOUR $ <br /> FEES ARE BASED ON THE 5130 HOURLY RATE. TME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY b AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECENED <br /> EH 23 032(REVISED 0344-14) <br />