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SAN doaQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT OCT 10 2016 <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www.sicehd.com <br /> FACILITY NAME <br /> FACILITY CONTACT NAME L� <br /> Lodi Memorial Hospital Randy DEPARTMENT <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 9 339-7667 <br /> 975 S Fairmont <br /> 20 <br /> CITY 7CA <br /> E ZIP CODE 7#OFETAN:KS AT SITE <br /> Lodi d _j <br /> 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 CONTRACTOR ICC# <br /> Closure installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 2010 2011 2012 2013 2014 2015 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK <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 Pias <br /> TANK ID# s : CLOSURE FEE_$390/TANK #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections tions <br /> TANK!D#(a): TEMPORARY CLOSURE FEE_$390/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction!ns ctions $ <br /> TANK ID#(s): PLAN CHECK FEE_$1040/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$3901 FACILITY (use for monitoring equipment cold starts,EVR upgrades, 417,00 <br /> s !U buckets,sumps,miser $ <br /> PIPING REPAIR FEE=$390/FACILITY use for ! ! ,under-di s neer containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 <br /> $ <br /> CONSULTATION FEE _ $134/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $130!HOUR <br /> $ <br /> SAMPLING INSPECTION FEE _ $130/HOUR <br /> FEES ARE BASED ON THE 5130 HOURLY RATE. TIME THAT EXCEEDS BEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $417.00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# V RECEIVED BY DATE RECEIVED <br /> EH 23 O32(REVISED 04.22-15) <br />