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SAN Y UIN COUNTY ENVIRONMENTAL HEALTH D RTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEc WORKSHEET <br />FAi;ILil Y NAME <br />FACILITY CONTACT NAME <br />e - G- C. f <br />���� k 0 <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />CITY A STATE <br />ZIP CODE # OF TANKS AT SITE <br />cIf'A i r' -z n I <br />APPLICANT Bl-LLINd NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />(209) 461-6337 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />STOCKTON <br />CA <br />95205 <br />1998 1999 2000 2001 12002 2003 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (51707X(#tanks) ($170)X(manks) <br />5125 PER TANK AFTER FIRST TANK — I — <br />$ <br />ANK PENA;_TY ASSESSED $ <br />T, NK SURCHAR.(:F = $10 / rqt-k. _ _ I $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY I $ <br />Removal or Permitted Closure in Place) <br />TANK ID 4 (s) : _ CLOSURE FEE _ $279 /TANK I # TANKS X $279 =— $ — <br />TEMPORARY Cl OSURE — — <br />:P,an Review and I,:spections, <br />TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check an,, -'Construct: )n inspections) <br />TANK ID # (s) : PLAN CHECK FEE = $744 / FACILITY $ <br />REPAIR PLAN CHECK <br />CHECK # RECEIVED BY I DATE RECEIVED <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />q <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ecL) <br />$ <br />MISCELLANEOUS <br />CHECK # RECEIVED BY I DATE RECEIVED <br />TRANSFER FEE _ $ 20 _ <br />$ <br />CONSULTATION FEE _ $ 93/ HOUR — _ <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />All CPMQADC DACCM-1ruor���,,�.--- <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED <br />CHECK # RECEIVED BY I DATE RECEIVED <br />SR <br />