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SAN JOAQUIN COUNTY <br /> EWRONMFNTAL HEALTH DuAwrMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Tekphome. (209)468-3420 Fox. (209)468-3433 Web:www.sjoehd.com VEL- <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Costco#1091 Rick A PIR 2 2 2 015 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 2680 Reynolds Ranch Parkway 209 461-6337 NVIRONMENTAI <br /> CITY I STATE ZIP CODE #OF TANKS AT 91'TE: <br /> Lodi CA 95240 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Kim White <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 I CONTRACTOR ICC# <br /> Stockton CA 96205 Closure Installation Repair Retrofit I <br /> ACTIVE FACILITY <br /> 2009 2010 2011 2012 2013 2014 <br /> $650 FEE INCLUDES FACILITY FEE+I TANK <br /> $130 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANKSURCHARGE=$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.001 FACILITY <br /> PERMANENTCLOSURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$390/TANK I #TANKS X$390 <br /> TEMPORARY CLOSURE <br /> (Pfan Review and frispections) <br /> TANK ID#(a): TEMRPORARY CLOSURE FEE=$3901 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$10401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$390/FACILITY (use for monitoring equipment cold starts,FVR upgrades, <br /> sLffl buckets,sumps,misc.) 390.00 <br /> PIPING REPAIR FEE=$390/FACILITY usefar piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $130f HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1301HOUR $ <br /> SAMPLING INSPECTION FEE = $13D/HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE.TIME THAT EXCEEDS FEES PAID WILL BE 80-LED TO APPLICANT. <br /> TOTAL AMOUNT DUE Is <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED EREEK3 RECEIVED BY DATE RECEIVED <br /> EN 23 032(REVISED 08-04-14) <br />