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SAN JOAQUIN COUNTY 0 ENVIRONMENTAL HEALTH DEPARTMENT 600 East Main Street, Stockton, CA 95202-3029 Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sogov.or /g ehd .JUN 2 4 2015 FACILITY NAME FACILITY CONTACT NAME KAISER HOSPITAL MANTECA.--NVIRONMB r FACILITY ADDRESS SITE PHONE # WITH AREA CODE ' 1777 W. YOSEMITE AVE 925 551-7555 CITY STATE ZIP CODE I # OF TANKS AT SITE MANTECA CA 95336 APPLICANT BILLING NAME APPLICANT CONTACT NAME Gettler Ryan Inc. MERLIN BOWEN APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 6805 Sierra Court, Suite G 925 551-7555 CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # Dublin CA 94568 Closure Installation Repair Retrofit $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) $125 PER TANK AFTER FIRST TANK Ml- qr-y- ACTIVE FACILITY TANK ID # (s): CLOSURE FEE = $315 / TANK 2004 2005 2006 2007 2008 2009 $500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) SAMPLING INSPECTION FEE _ $ 105/ HOUR $550 FEE INCLUDES FACILITY FEE + 1 TANK (2008-2009) $125 PER TANK AFTER FIRST TANK $ TANK PENALTY ASSESSED TANK SURCHARGE = $15 / TANK Is STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s): CLOSURE FEE = $315 / TANK # TANKS X $315 = TEMPORARY CLOSURE Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $315 / FACILITY INSTALLATION PLAN CHECK Plan Check and Construction Inspections) TANK ID # (s) : I PLAN CHECK FEE = $840 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : TRANSFER FEE _ $ 20 TANK RETROFIT REPAIR FEE = $315 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, 390 spill buckets, sumps, misc. PIPING REPAIR FEE = $315 / FACILITY (use for piping, under -dispenser containment, ect.) MISCELLANEOUS TRANSFER FEE _ $ 20 CONSULTATION FEE _ $ 105/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $ 105 / HOUR SAMPLING INSPECTION FEE _ $ 105/ HOUR ALL FEES ARE BASED ON THE $105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # I RECEIVED BY I DATE RECEIVED SR EH 23 032 (REVISED 03/20/09)