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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone.(209)468-3420 Far.(209)468-3433 Web:www.sicehd.com <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Lodi Memorial Hospital Randy <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 975 S Fairmont ( 209 1 339-7667 <br /> I CITY STATE ZIP CODE I #OF TANKS AT SITE <br /> Lodi CA 95240 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Me an Mitchell <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE III WITH AREA CODE <br /> 2535 Wigwam Dr (209 ) 461-6337 <br /> CITY STATE ZtP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 4COnI Ga I UDZU0 Closure Installation Re air Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2010 2011 2012 2013 2014 1 2015 <br /> $130 PER TAW AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TAW <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): CLOSURE FEE=$390/TANKT #TANKS X$390= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE $390 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Ins ons <br /> TANK ID#(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 /> 456.00 <br /> spill buckets,sumps,misc.) <br /> $ <br /> PIPING REPAIR FEE $390 FACILITY use for p! irg,under-d !nm <br /> a II,Noma v4wer <br /> MISCELLANEOUS <br /> 7v 15 ZU11 <br /> TRANSFER FEE $25 <br /> CONSULTATION FEE $130/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE $130/HOUR PERART44ENT <br /> SAMPLING INSPECTION FEE $130/HOUR I $ I <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERVICIEREQUEST# I FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED BY I DATE RECEIVED <br /> EH 23 032(REVISED 04-22-15) <br />