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, ��:® ® Elite IV Contactors 114TY 6342 <br /> VSAN JOAQUJN COUNTY �} 11 �� �}FP•' 1 <br /> ENVIRONMENTAL HEALTH DEPARAT ' CLI J 611 L V-, <br /> 1868 E.Hazelton Ave., Stockton,CA 952115 ;232 10)i�q <br /> OCT 2 9 2014 Telephone: (209)468-3420 Fax:(209)468-3433 Wet: ✓ww.sicehd.com <br /> FACILITY NAME FACILITY CONTA, T NAME <br /> ENVIRONNIF" 6a , - — <br /> DEP? FACILITY ADDRESS .SITEPHO E#1111 HAREA CODE <br /> CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> ICA <br /> APPLICANT FULLING NAME / APPLICANTCOIJ' �,CT NAME <br /> s / 1V I <br /> APPLICANT MAILING ADDRESS APPLICANT PHIN #NTH AREA CODE <br /> L IA / a r �` i , (_ <br /> CITY ,� S TE P CODE CIRCLE W0121 TO BE DONE CONTRACTOR ICC# <br /> Gosure Installalio R it ReWfit <br /> ACTWE FACILITY — <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2009 2010 20' 1 2012 2013 ' 2014 <br /> $130 PER TANK AFTER FIRST TANK — <br /> TANK PENALTY ASSESSED $ ' <br /> TANK SURCHARGE=$151 TANK _ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA FIR GRAM=$35.001 FACILITY $ <br /> PERMANENT CLOSURE - <br /> Removai or Permitted Closure in Place _ <br /> TANK 10#(a); CLOSURE FEE= 390/Trs_ : #TANKS X$390= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) _ <br /> TANK ID#(s): TEMPORARY CLOSUREFE =$3901 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Chedc and Consfmcfion Inspections) _ <br /> TANK ID#(s): �— $ <br /> PIAN CHECK FiiE =$1040!FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$390/FACILITYuse for monitoring $ <br /> ( m9 equipment,aad ;tarts,EVR upgrades, <br /> spill buckets Sumps,misc.)_ <br /> PIPING REPAIR FEE=$3901 FACILITY use for piping.under-dis eraser ccm unment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 _ $ <br /> CONSULTATION FEE = $130/HOUR _ $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $1301 HOUR $ <br /> SAMPLING INSPECTION FEE = $1301 HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE EIIL M TO APPLICANT. <br /> TOTAL AMOUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# I PACIUTY In I AMOUNT RECEIVED I CHECK# � RECEIVED BY I DATE RECENED <br /> EH 23 032 rREVISED 08-04.141 <br />