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0 SAN JOAQUIN COUNTY RECEIVEb <br /> ENVIRONMENTAI,HEALTH DEPARTMrNT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 NOV 19 2015 <br /> Telephone.(209)468-3420 Fax. (209)468-3433 Web.AjnLs'cehd.com <br /> L_ <br /> FACILITY NAME FACILITY CT NAME LA <br /> I <br /> L <br /> Knifes River <br /> V <br /> FACILITY <br /> ADD John or Rodger <br /> SITE PHONE#WIPITHAREA CODE <br /> CITY 655 W. Clay St. I ,". <br /> CITY -L209-L 932-2126 <br /> —TS—TATE LZIP CODE #OF TANKSAT SITE <br /> 95206 �.Stockton CA tt�� <br /> APPLICANT BILLING <br /> CONTAC AME <br /> Elite IV Contractors <br /> APPLICANT MAILING ADDRESS APPLICANT PHON #WITH AREA <br /> CODE <br /> 2535 Wigwam Dr. 20 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> C10surO Installation R air Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2009 2010 2011 2012 2013 2014 <br /> $130 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SU <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35.001 FACILITY <br /> PERMANENT QvUURE <br /> (Removal or Permitted Closure in Place) <br /> TANK ID fla): CLOSURE FEE=$390 TANK #TANKSX$�390= <br /> TEMPORARY CLOSURE ---- <br /> HPIan Review and Inspections) <br /> TANK ID#(a): TEMPORARY CLOSURE FEE=$390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK 10#(s): 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, <br /> __:" b-i—els,sumps,misc.) 390.00 <br /> PIPING REPAIR FEE $3901 FACILITY use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130/HOUR $ <br /> SAMPLING INSPECTION FEE = $130/HOUR $ <br /> FEES ARE BASED ON THE$116'HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL OUNT DUE <br /> OFFICE USE ONLY <br /> ..SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED <br /> I- ICHECK_ - --T RECEIVED BY PATE RECENED <br /> EH 23 032(REVISED 084414) <br />