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0�/15/2002 02:43 2093397651 LMH MTC SHOP PAGE 05/05 <br /> 0 0 1 <br /> SCT <br /> ,SAN OONY RECENED <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 1868 E.Hazelton Ave,,Stockton.CA 95205-6232 OCT 3 1 2017 <br /> relephone:(209)46R-342017a . (209)468-3433 We& 3MWjv.s' eh .Tom <br /> FACILITY NAME FACILITY CONTACT NAME 11 V I ltt�tltHEWI AL HEALTH <br /> Lodi Memorial HosEital Randy IENT <br /> FACILITY ADDRESS BITE PH NE ig WrrH AREA CODE <br /> –975 S Fairmont ( 209 ) 339-7667 <br /> -—-------- STATE I ZIP CODE #UFURKS AT SITE <br /> Lodi CA 95240 <br /> APPLICANT BILLING NAME -AP–PLCA ICON ACT NAME <br /> Elite IV C-ontractors Megan Mitchell <br /> APPLICANT MAILING ABDRESS APPLICANT PHONEIWITH AREA 05! <br /> 2535 Wigwam DrJ461-6337 <br /> 2Q9 <br /> CITYCIRCLE WORK TO BE DONE CONTRACTOR FCC# <br /> –7SOC On Closure Installation R�eg��Rojrorjj <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY 2015 <br /> $130 PER TANK AFTER FIRST TANK 2010 2011 2014 FACILITY FEE+1 TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> 1 STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$35,001 FACILITY $ <br /> PERMANENT CLOSURE <br /> (Removal or�Pem�ittgd�Closure in Plne).__ <br /> TANK ID#(s): I CLOSURE FEE-.,$3901 TANK 4 TANKS X$390 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK 10 N(s): CLOSURE FEE m$390 f FACILITY <br /> INSTALLATION PLAN C9ffdT_" <br /> fPlam Check and Consjtryctlon Ins actions <br /> TANK 10#(a): PLAN CHECK FEE=$10401 FACILITY $ <br /> REPAIRPLANCH- <br /> -K <br /> 7A_NR 16;(s): <br /> TANK RETROFIT REPAIR FEE $390 f FACILITY (use for monitoring equipment,colo Starts,EVR upgrades, $ <br /> bucket,%sp–ps,mist,) 456.00 <br /> ont.Oct.) <br /> MISCELLANEOUS <br /> TRANSFER FEE $25 $ <br /> CONSULTATION FEE = $1301 HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE $130 HOUR <br /> SAMPLING INSPECTION FEE $1301 HOUR <br /> _s ARE <br /> BASED ON THE$130 HOURLY kATE. TIME—THAT EXCEEDS FEENPAFGWILL L;'E 15ILL00 AMIGANT, <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY 56=00 <br /> SERVICE REQUEST f FACILITY Ip AMO MT RE4fwIVSi3 CHECK# IVED By 6ATE APCE-IvIt-p <br /> EM 23 032(REVISED 904-22-13) <br />