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SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTri DEPARTMENT <br /> 1868 E.Hazelton Ave.,Stockton,CA 95205-6232 APR 14 <br /> Telephone:(209)468-3420 F(w(209)468-3433 Web:www.sicehd.coni <br /> FACILITY NAME U <br /> FACILITY CONTACT NAME <br /> vv <br /> Lodi Memorial Hospital Carrie 209461-6337 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 975 S. Fairmont 209 1 339-7667 <br /> CITY -TATE ZIP CODE <br /> OF TANKS AT SITE <br /> Lodi CA 95240 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite IV Contractors Kim White <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr. 20 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK 2009 2010 2011 2012 2013 2014 <br /> $130 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$15/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$35.00/FACILITY <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place) <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 1 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <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 /> 390.00 <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE $390 FACILITY use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE $25 $ <br /> CONSULTATION FEE $130/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE $130 1 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 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 08-04-14) <br />