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Nov 20 14 02:02p Eli tia Iv Contractors Inc 209461W2 P. 3 <br /> .. 9 - EIVED <br /> SAN JOAQUIN COUNTY REG <br /> ENWRONMENTALHEALTH DE-PARTMENT <br /> 1868 E.HavAlton Ave.,Stockton,CA 95205-6232 NOV 2 0 2014 <br /> Telephone:(209)468-3420 F=(209)468.3433 Web:www.,;icc 'mr'n <br /> FACILITY NAME FACILITY CONTACT NAME <br /> HEALTH <br /> FACILITYDEPARTMENT <br /> MEMOS- SM PHONE-0 WITH AREA COQE <br /> I C-C <br /> CITYLSTATt TE nn- <br /> - zwe =FTAN <br /> KS AT SITE <br /> ICA <br /> .APPLICANT BILLIN-0 NAME APPLEANT CONTACT-N—AME <br /> E LITLa <br /> APPLICANT <br /> MAILING At3DIT APPLICANT PHONE#WITH AREACODE <br /> CITY <br /> STATE QIP CODE CIRCLE WORK TO SE DONE CONTRACTOR ICC sI <br /> Non ftetroflt <br /> ACTIVE FACIu77 <br /> $550 FEE INCLUDES FACILITY FEE+I TAW 2009 2010 2011 2012 2013 2014 <br /> $130 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$1$I TAW $ <br /> STATE SURCMARGE FOR FACILITdCS NOT ALREADY ON INVENTORY IN A CUPA PROCRAM r.$35.001 FACILITY $ <br /> "PERMANENT CLOSURE <br /> (Removal orftnittadClosure inftca) <br /> TANK ID#(s)! CLOSUK FEE=$3901 TANK I --4,TANKS X$300= $ <br /> TEMPO CLOSURE <br /> (Plan Review and Ins PqcUorfs <br /> _, <br /> FTANKIDOW; TEMPORARY CLOSURE FEE=VAO I FACILITY <br /> -WSTALL—ATioN PLAN cmeclK <br /> Pian Check and Construction lmppgLwjm <br /> TANK ID#(a): PLAN CHECK FEE=$10401 FACILITY S <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> M LO $ <br /> TANK RETROFIT REPAIR FEE =$390/FACILITY (use for monitoring aquipment,odd starts,EVR upgrades, <br /> spill pupkeb%sumps,misc.) <br /> gJit L $,,,-- <br /> PIPING REPAIR FEE=$390/FACILITY use for pipimunder-di,und -dispensercontmirtment,ed.) <br /> MISCELLANEOUS <br /> TRANSFER FEE = $25 $ <br /> CONSULTATION FEE 1301 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE ;-- $130/mOUR $ <br /> SAMPLINC INSPECTION FEE _ $1 30/HOUR I $ <br /> limI <br /> FEES ARE BASED ON TIM$130 BURLY TIME THAT EXCEEDS PAID WILL ff&-BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE -T$ <br /> OFFICE USE ONLY <br /> -SERVICE REQUEST 0 MeILITY 10 AMOUNT RECEIVED CH9CX 0 RECEIVED BY I DATE RECEIVED <br /> EH 23 032—IRE"SED W-04141 1 <br />