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s Q . J A U Environmental Health Department <br /> ----- COU N T Y <br /> FACILITY NAME Lodi Memorial Hospital FACILITY CONTACT NAME Randy <br /> FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br /> 957 S Fairmont Ave ( 209 ) 339-7667 <br /> CITY STATE ZIP CODE # OF TANKS AT SITE <br /> Lodi CA 95240 <br /> APPLICANT BILLING NAME Elite IV Contractors APPLICANT CONTACT NAME <br /> Megan Mitchell <br /> APPLICANT MAILING ADDRESS 2535 Wigwam Dr APPLICANT PHONE # WITH AREA CODE <br /> 209 461 -6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC # <br /> Stockton Ca 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> UST FEES = $550 2014 2015 UST FEES 2016 UST FEES 2017 VPH UST FEES = 2018 $ <br /> ( Facility+ 1st = $583 = $641 $961 Facility + <br /> Tank) + $130/Tank Facility + Facility + $228/Tank <br /> after 1st $ 139/Tank $152/Tank <br /> Double Wali & 1702 $ <br /> Compliant UST <br /> FEES = $680 <br /> Facility + $228/Tank <br /> Tank Penalty $ <br /> Assessed for <br /> Unreported Tanks <br /> (Based on Annual <br /> Permit Fees <br /> TANK SURCHARGE _ $201 TANK <br /> $ <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 = $4561 TANK # TANKS X $456 = $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> $ <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 = $3,040 / FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID # (s) : <br /> TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, Cold Starts, EVR upgrades, 456.00 <br /> Spill buckets, sumps, mist. <br /> PIPING REPAIR FEE = $456 / FACILITY use for piping, under4s enser containment, etc. <br /> MISCELLANEOUS <br /> TRANSFER FEE = $ 25 $ <br /> CONSULTATION FEE _ $ 1521 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 1521 HOUR $ <br /> SAMPLING INSPECTION FEE _ $ 1521 HOUR $ <br /> FEES ARE BASED ON THE $152 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $ 456 .00 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED <br /> 1868 E . Hazelton Avenue Stockton , California 95205 ( T 209 468-3420 F 209 464-0138 1 www.sjcehd .com <br /> i <br />