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0 SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />1868 E. Hazelton Ave., Stockton, CA 95205-6232 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.siceh .cop <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />San Joaquin General Hospital <br />FACILITY ADDRESS <br />500 W Hospital Rd <br />SITE PHONE # WITH AREA CODE <br />209-468-6812 <br />APPLICANT MAILING ADDRESS <br />ZIP CODE #OF TANKS <br />L�FrenchCamp CA <br />95231 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Bagley Enterprises, Inc <br />Joseph Bagley <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2370 Maggio Cir #4 <br />20 367-4800 <br />CITY Lodi STATE ZIP <br />CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br />Facility Fee NO LONGER INCLUDES FIRST TANK <br />Closure Installation Repair Retrofit 8014628 <br />ACTIVE FACILITY <br />TANK ID # (s): <br />(As of 8/1/16) $583 FACILITY FEE + $139 PER TANK <br />2011 <br />2012 <br />2013 <br />2014 <br />2015 <br />2016 <br />$ <br />Facility Fee NO LONGER INCLUDES FIRST TANK <br />(2011 -Aug 1, 2016) $550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />$130 PER TANK AFTER FIRST TANK <br />$ <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): <br />CLOSURE FEE = $417 / TANK <br /># TANKS X $417 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $417 / FACILITY <br />INSTALLATION PLAN CHECK <br />Plan Check and Construction Inspections) <br />$ <br />TANK ID # (s) : PLAN CHECK FEE = $1112 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $417 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ <br />spill buckets, sumps, misc. <br />$ <br />PIPING REPAIR FEE = $417 / FACILITY use for piRing, under -dispenser containment, ect. <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 139/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 139 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = $ 139/ HOUR <br />$ <br />FEES ARE BASED ON THE $139 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 07-15-2016) <br />