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SANLIN COUNTY ENVIRONMENTAL HEALTH RTMENT <br /> UNDERGROMD STORAGE TANK PROGRAM FIT WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> fi't (244 <br /> FACIL DRES S PHONE# EA CODE <br /> MOD Hw`V5b-'07rias-SLW2 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ELITE IV CONTRACTORS, INC. CARRIE MILLER <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 WIGWAM DRIVE <br /> 209 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> STOCKTON CA 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> : .$500 FEE INCLUDES.FACILITY FEE+1 TANK ($170)x(ganks) ($170)x(7Aank) - - - - - <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place - <br /> TANK ID#(S)' <br /> CLOSURE FEE_$279/TANK #TANKS X$279= $ <br /> TEMPORARYCLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY $ <br /> INSTALLATION PLAN CHECK - <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $ - <br /> REPAIR PLAN CHECK <br /> i , <br /> TANK ID# s <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment spill buckets,tank sumps,mist.) $� <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ect <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR - $ <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. -� <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECENED <br /> SR __ <br /> EH 23 032(REVISED 8101/03) <br />