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SAN <br /> UIN COUNTY ENIRONMENTAL HEALTH <br /> RTMENT <br /> UNDERGR(7RJD STORAGEvTANK PROGRAM F WORKSHEET <br /> FACILI NAME <br /> FACILITY CONTACT NAME <br /> 63 <br /> FACILITY AD 07 CQ <br /> S PHONE#WITH AREA—CODE <br /> CITY / <br /> 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 /> CITY STATE ZIP CODE � 209) 461-6337 <br /> CIRCLE WORK TO BE DONE: <br /> STOCKTON CA 95205 <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 199E 1999 200 _,20M 200? , 2003 <br /> _. -: .-4.55011 F8F_IPIF.LUOE:r{AEILITI'FEE -I TANK _._ - - <br /> I $1^5 PER TANK AFTER FIRS r TANK - <br /> $ <br /> TANK PENALTY ASSESSED - $ <br /> TANK SURCHARGE=$10/TANK $ <br /> S TATE SURCHARGE FOR FACILITIES NOT At ON INVENTORY INA CUPA PROGRAM $17 501 FACILITY I <br /> PERMANENT CLOSURE -_ <br /> Removal or.Permitted Closure in f lace - .. <br /> [TANK <br /> ANK ID#R : CLOSURE FEE_$279/TANK #TANKS X$279= $ <br /> EMPORARY CLO SURE <br /> lan Review and Inspections) <br /> ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY - $ <br /> INSTALLATIONPLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s)-: PLAN CHECK FEE_$744/FACILITY $ <br /> FREPAIR CHECK <br /> IT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mist.)R FEE =$279/FACILITY (use for piping,under-dis iser- - $ '. <br /> containment,ect - <br /> . .MISCELLANEOUS_ <br /> I <br /> TRANSFER FEE _ $?0 <br /> I <br /> CONSULTATION FEE = $931 HOUR - - _� $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR $ !1 I <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$83 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE SM.1 M TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY IOLSR <br /> - AMOUNT RECENED CHECK# RECEIVFJ)BY DATE RECFNED �: <br /> El23032(REVISED 8/01/03) <br />