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SAN dOAQUiN CQIJN'I'Y 4�IECEIVED <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 FACILITY CONTACT NAME LTH <br /> Lodi Memorial Hospital Randy ®EpARTMENT <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 975 S Fairmont di2f <br /> CITY STATE k139-7667 <br /> #OF TANKS AT SITE <br /> Lodi CA <br /> APPLICANTBILLING 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 /> btocKion CA 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=$35.001 FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place $ <br /> TANK ID#(s): CLOSURE FEE=$3901 TANK #TANKS X$390= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$396/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) $ <br /> TANK ID#(s): PLAN CHECK FEE=$10401 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 ill buckets,sum s,misc. <br /> PIPING REPAIR FEE_$390/FACILITY use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 <br /> CONSULTATION FEE = $1301 HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1301 HOUR <br /> SAMPLING INSPECTION FEE = $130/HOUR <br /> FEES ARE BASED ON I HEIS1130 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE 417.00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECENED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED 0422-15) <br />