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�ry�j Q Q UNEnvironmental Health Department r < G; -Atonvss craw.= s fir,= re . FACILITY NAME FACILITY CONTACT NAME od ' a and Roehrich FACILITY ADDRESS SITE PHONE # WITH AREA CODE 975 S . Fairmont Ave 209 334-3411 CITY STATE ZIP CODE # OF TANKS AT SITE Lodi CA 95240 APPLICANT BILLING NAME APPLICANT CONTACT NAME Elite IV Contractors Carrie Miller APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2535 Wigwam Dr if 209 461 -6337 - Cell 9934267 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE7]7 CONTRACTOR ICC # Stockton I CA 195205 Closure Installation Repair Retrofit ACTIVE FACILITY UST FEES = $641 Facility Fee + $152 Per Tank 2012 2013 12014 2015 2016 2017 $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $20 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.00/ FACILITY PERMANENT CLOSURE Removal or Permitted Closure in Place $ TANK ID # (s) : CLOSURE FEE = $456 / TANK # TANKS X $456 = TEMPORARY CLOSURE Plan Review and Inspections) h TANK ID # (s) : TEMPORARY CLOSURE FEE _ $456 / FACILITY $ v INSTALLATION PLAN CHECK Pian Check and Construction Inspections) TANK ID # (s) : PLAN CHECK FEE = $ 1216 / FACILITY $ �\ REPAIR PLAN CHECK V TANK ID # (s) : TANK RETROFIT REPAIR FEE _ $456 / FACILITY (use for monitoring equipment, cold starts, EVR upgrades, $ `I spill buckets , sumps , misc.) OV PIPING REPAIR FEE = $456 / FACILITY (use forpiping, under4s enser containment, ect.) $ 456 . 00 1 MISCELLANEOUS Si t1 ' p TRANSFER FEE = $ 25 CONSULTATION FEE _ $ 152/ HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE _ $ 152 / HOUR $ SAMPLING INSPECTION FEE _ $ 152/ HOUR $ FEES ARE BASED ON THE $162 HOURLY RATE, TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT, TOTAL AMOUNT DUE $ OFFICE USE ONLY SERVICE REQUEST # I FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED 1868 E . Hazelton Avenue ( Stockton , California 95205 T 209 468-3420 I F 209 464-0138 1 www. sjcehd . com