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SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTN4ENT I <br />., <br />1868 E. I-Iazel[on Ave„ Stockton, CA 95205-6232 6, <br />Telephone: (209) 468-3420 Far: (209) 468-3433 Web: www.sicehd.com <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Elite IV Contractors <br />Swaran Chouchan'"r�4 jMy" <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />2535 Wigwam Dr <br />(2 09) <br />CITY <br />STATE ZIP CODE # OF TANKS AT SITE <br />STockton <br />CA 95205 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />Elite IV Contractors <br />Kim White <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 Wigwam Dr. <br />20 461-6337 <br />CITY <br />STATE <br />I ZIP CODE CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />PIPING REPAIR FEE = $390 1 FACILITY use for piping, under -dispenser containment, ect. <br />Closure Installation Repair Retrofit <br />$ <br />ACTIVE FACILITY <br />TANK ID # (s): <br />CLOSURE FEE = $390 I TANK <br />2009 <br />2010 <br />2011 <br />2012 <br />2013 <br />2014 <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK <br />$ <br />PIPING REPAIR FEE = $390 1 FACILITY use for piping, under -dispenser containment, ect. <br />$ <br />SAMPLING INSPECTION FEE _ $ 130/ HOUR <br />$130 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <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 = $390 I TANK <br /># TANKS X $390 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $390 / FACILITY <br />INSTALLATION <br />!Pian Check and <br />TANK ID # <br />PLAN CHECK FEE = $1040 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />$ <br />TRANSFER FEE _ $ 25 <br />TANK RETROFIT REPAIR FEE = $390 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, <br />390.00 <br />spill buckets, sumps, misc. <br />$ <br />PIPING REPAIR FEE = $390 1 FACILITY use for piping, under -dispenser containment, ect. <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 25 <br />$ <br />CONSULTATION FEE = $ 1301 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 130 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 130/ HOUR <br />FEES ARE BASED ON THE 4130 HOURLY KA It. I ImE INA I EXCEEDS FEES t'Aiu "!L. nc ole u u r rru nn <br />TOTAL AMOUNT DUE $ 390.00 <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK N RECEIVED BY DATE RECEIVED <br />EH 23 032 (REVISED 08-04-14) <br />