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SAN J UIN COUNTY ENVIRONMENTAL HEALTH ARTMENT <br /> UNDERGRMND STORAGE TANK PROGRAM - WORKSHEET <br /> ` FACILITY NAME FACILITY CONTACT NAME <br /> -Cml if i 41l <br /> FACILITY ADDRF S U SITE PHONE 4 PATH AREA CODE <br /> "7'P7-,"Z <br /> CITY STATE ZIP CODE I #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 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 1 2002 1 2003 <br /> $500 FEE INCLUDES FACILITY FEE+I TANK ($170)X(#lanks) ($170)X(#Ianks) <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 /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE_$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> jPIan Review and Ins actions) <br /> . Ti1rJV ID#(s): TEMPORARY CLOSURE FEE-$279/FACILITY <br /> I (NS iALLATION PLAN CHECK <br /> 1 (PlanC� heck and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mise) <br /> $ <br /> PIPING REPAIR FEE =$279/FACILITY use for piping,under-dispenser containment,act) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR <br /> $ <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 SR CHECK# ENED BY i DATE RECEIVED- REC �L <br /> EH 23 032(REVISED 8101103) <br />