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0 RECEIVED ' <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT FEB 0 1 2017 <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.com <br /> FACILITY NAME FACILITY CONTACT NAME '- ENVIROMAIPOTIAL HEALTH <br /> r <br /> Lathrop Shell Chris )EMH I ME F <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 16500 S Harlan Rd ( 209 ) 983-0381 <br /> CITY STATE ZIP CODE :I—#OF TANKS AT SITE <br /> Lathrop CA ubztju I <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 /> StocKton ua titmuo Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2010 2011 2012 2013 2014 1 2015 <br /> $130 PER TANK AFTER FIRST TANK $ <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 /> PERM ANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$390/TANK #TANKS X$390 <br /> TEMPO RARYCLOSURE <br /> (Plan Review and Ins ons <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$3901 FACILITY 1 $ 1 <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(a): 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, 417.00 <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE=$390/FACILITY use for pipin2,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 THE 6130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $417.00 <br /> OFFICE USE ONLY <br /> SERVICEREQUESTREQUEST# FACILITY ID T-AMOUNT RECEIVED I CHECK 0 RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 04-22-15) <br />