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SAN JOAQUIN COUNTY 4hEGRA' gED <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 141114 2 n R FIT[AL <br /> Lodi Memorial Hospital Randy D E PAJ,D,7 ,EN F <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 975 S Fairmont ( 209 1 339-7667 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> Lodi CA 95240 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Megan Mitchell <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr (209 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE =ONTRACTOR ICC# <br /> OC on I Ga 1 205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2010 2011 2012 2013 2014 1 2015 <br /> $130 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=$35.00/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <br /> $ <br /> TANK ID#(s): CLOSURE FEE=$390/TANK #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 Inspections) <br /> TANK to#(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 /> spill buckets,sumps,misc.) 456.00 <br /> PIPING REPAIR FEE=$390/FACILITY use for piping,under-dispenser containment,act.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE = $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $130/HOUR $ <br /> SAMPLING INSPECTION FEE = $130/HOUR $ <br /> FEES ARE BASED ON THE$130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE -F$-456.001 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 0422-15) <br />