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A 'rvf�X*Z' <br /> SKJOAQ11N Environmental Health Department <br /> COUNTY d r &j fi)�geGreatness grows here, <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Lodi r' I 7 ' Randy Ro hric <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 975 S. Fairmont Ave 209 334-3411 <br /> r��LI STATE ZIP CODE #OF TANKS AT SITE <br /> Lodi CA 95240 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Elite on rac ors Carrie Miller <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 Wigwam Dr 209 461-6337-Cell 993-4267 <br /> CITY I STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> CA 195205 1 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES= $641 Facility Fee+$152 Per Tank 2012 2013 2014 2015 2016 2017 <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$20/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s : CLOSURE FEE=$456/TANK 1 #TANKS X$456= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$456/FACILITY $ <br /> INSTALLATION PLAN CHECK ' <br /> (Plan Check and Construction Inspections) <br /> $ <br /> TANK ID#(s): PLAN CHECK FEE=$1216/FACILITY l <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$456/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ `I <br /> spill buckets,sumps,misc.) (I�U <br /> PIPING REPAIR FEE_$456/FACILITY use for piping,under-dispenser containment.ect. $456.00 �r <br /> MISCELLANEOUS t� <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE = $152/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $152/HOUR $ <br /> SAMPLING INSPECTION FEE _ $152/HOUR $ <br /> FEES ARE BASED ON THE$162 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 RECEIVER CHECK# RECEIVED BY DATE RECEIVED <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 4640138 1 www.sjcehd.com <br />