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SAN JOAQUIN COUNTY REGFNED <br /> ENVIRONMENTAL HEALTH DEPARTMENT NOV 2 12017 <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fat:(209)468-3433 Web:www.sj o� v.or <br /> FACILITY NAME FACILITY CONTACT NAME E <br /> City of Lodi Randy Laney ` I <br /> EN <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1331 s Ham Lane 209)333-6800 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Lodi I CA 95242 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Baq tey Entiegrisek, Incl. Jowph.Bagley <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2370 Ma"i&CL+rc&S"We,4 209 367-4800 <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CA 195240 Closure Installation Repair Retrofit 18014628 <br /> ACTIVE FACILITY <br /> 2006 2007 2008 2009 2010 2011 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK(2006-2007) <br /> $550 FEE INCLUDES FACILITY FEE+ 1 TANK(2008-2011) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$366/TANK #TANKS X$366= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): I TEMPORARY CLOSURE FEE_$366/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$976/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, 456 <br /> spill buckets,sumps,mist. <br /> PIPING REPAIR FEE _$366/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $ 122/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $122/HOUR $ <br /> SAMPLING INSPECTION FEE = $ 122/HOUR $ <br /> ALL FEES ARE BASED ON THE$122 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ 456. <br /> OFFICE USE ONLY <br /> [SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 06/3/11 by KF) <br />