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�. S#JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE—PARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FA RM NAME _ FAC)U Y CONTACT NAME - .. <br /> 0 hale a fi <br /> FACILITY ADDRESS - 5 WITH AREA CODE <br /> ale m _ q75- 9190 <br /> CfTY - STATE ZIP CODE 6 OF 7ANKS Al SITE . <br /> �-� <br /> CA <br /> APPLICANT BILLING NAME - - - - APPLICANT CONTACT NAME <br /> ELITE IO CONTRACTORS, INC_ CARRIE MILLER <br /> APPLICANT MAILRiG ADDRESS. APPLICANT PHONE OW AREA CODE . <br /> 2535 .WIGWAM DRIVE ( 209) .461-6337 <br /> CITY STATE - I ZIP CODE CIRCLE WORK TO BE DONE <br /> . -STOC'sCTON CA -95205 Closure imtaTation Repair Retrofit <br /> .ACTIVE FACLLfTY1998 - 1999- 2000 2001 . 2002 2003 <br /> _ SSOO FEE + <br /> INCLUDES FACILITY FEEI TANK- fsno)xlmmu* tsimtx(s -) .. . .. - _. - . . . <br /> . I5725 PER YANK AFTER FlRSTTAROC �. $ <br /> $ <br /> TANK FENALTYASSESSED <br /> TANK SURCHARGE=$10/TANK - - <br /> STATE SU1T <br /> SURCHARGE FOR FAC61ES NOT ALREADY ON WNTORY-IN A COPA PROGRAM 417.W FAC1tITY <br /> -(-PFRiAANENTCLOSURE(Rernoval _ . . . <br /> wPelmRted Cion in Place - .-. -- - <br /> $ <br /> TANK IDs(s) CLOSIRE FEE=.$279 PTANK sTANKSX$279= . .: . .•... . <br /> TEMPORARY CLOSl1RE - - <br /> (Plan Review and kmpecGovz) . <br /> TANK ID.s(s): TEIPORARY CLOSURE FEE_$2791 FACILITY <br /> r - INSTALLAAON-PLAN.CNECK - . . . . <br /> Check and ConsNrSon LapeCho ) <br /> TANK IDA(s)- '. .- PLAN CHECK FEE—$744/FACILITY 1 <br /> - REPAIR PLAN CHECK - <br /> i <br /> $.-,_,�. . <br /> TANK RETROEfi REPAIR FEE _$279/FACILITY (use for tm f�ing equipment spri&xka .tank Atm mise) <br /> plptNGREPAIR FEE =$279/FACHJTY (useforpipdsFunderdspenser m�L ea) 1 <br /> MISCELLANEOUS - .. . . <br /> - $ <br /> TRANSFER FEE =.$20 <br /> CONSULTATION FEE : _ $931 HOUIR -- —"� <br /> $ I <br /> UNAUTHORIZED RELEASE EVALUATKXd FEE ._ $931 H= <br /> $ <br /> SAMPLING WSPECAON FEE _ $93/HOUR <br /> . • ALL FEES"AfiE 60.5m ON 7NE 593HWRLY RATE <br /> TME THAT(7CC®StTFS PAID WILL BE BLL Urn TOAPPUCANF- <br /> OMCE USE ONLY <br /> SERVICE REQUEST s I FAL61TYo I T CHECK# ' :. RECHVED BY ixtTE RECEIVED _ _ I <br /> 3R <br />