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RECEIVED <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT OCT 0 9 2095 <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.cot <br /> IRONMENTAL <br /> FACILITY NAME FACILITY CONTACT NAME a OT44C NT <br /> Lodi Memorial Hospital Carrie 209-461-6337 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 975 S. Fairmont 339-7667 <br /> CITY I STATE I ZIP CODE #OF TANKS AT SITE <br /> Lodi CA 95240 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Kim White <br /> APPLICANT MAILING ADDRESS APPLICANTPHONE#WITH AREA CODE <br /> 2535 Wigwam Dr. 20461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DOME CONTRACTOR ICC# <br /> StoCkfr,in )5 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 209 2010 2011 2012 2013 2014 <br /> $130 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15 f TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$35.001 FACILITY <br /> PE ENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$390 t TANK #TANKS X$390= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ori <br /> TE <br /> TANK ID#(s): MPORARY CLOSURE FEE=$390 l FACILITY <br /> INSTALLATION PLAN CHECK <br /> Pian Cheat and Constriction Ins ectlons <br /> TANK ID#(s): PLAN CHECK FEE $1040/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$3901 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 590.00 <br /> spill budwts.sums mise. <br /> PIPING REPAIR FEE=;$3901 FACILITY use for piping,under-dispenser containment ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $1301 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130 1 HOUR $ <br /> SAMPLING INSPECTION FEE = $1301 HOUR $ <br /> FEES ARE BASEL}ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE Is I <br /> OFFICE USE ONLY <br /> SERVICEREQl1E$T# FACWTYiD A-BUNTRECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 08.04.14) <br />