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r Z51 VIP, <br /> S JOAQUIN Environmental Health Department <br /> r <br /> 1 COUNTY lat 0�e . <br /> Greatness grows here. <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 975 S. Fairmont Ave 209 334-3411 <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> Lodi =CA 95240 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Bile IV Contractors Carrie Miner <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 /> $ <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 /> $ <br /> TANK ID#(s): CLOSURE FEE=$456/TANK #TANKS X$456= <br /> TEMPORARY CLOSURE <br /> Ptan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$456/FACILITY $ <br /> INSTALLATION PLAN CHECK �I <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1216/FACILITY $ ``r, <br /> REPAIR PLAN CHECK <br /> 1 <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$456/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets sums mise. <br /> PIPING REPAIR FEE_$456/FACILITY use for piping,under-dispenser containment,ect. $456.00 <br /> MISCELLANEOUS i <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 /> T®TAL AM RUNT DUE $ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# j FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> 1868 E. Hazelton Avenue I Stockton, California 95205 1 T 209 468-3420 1 F 209 464-0138 1 www.sjcehd.com <br />