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SAANNf�QUIN COUNTY ENVIRONMENTAL HEALTH�+RTMENT <br /> UNDERGR <br /> D STORAGE TANK PROGRAM F WORKSHEET <br /> FArII.ITY NAME I,FACILITY CONTACT . <br /> Cion-ona in <br /> FACILITY ADDRESS S PHONE# AREA CODE <br /> 9 cx() <br /> :rTYY - STATE ZIP CODE 0 OF TANKS AT SITE <br /> CA J <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 Clmur6• Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 . 2000 2001 2002 2003 <br /> . $500 FEE INCLUDES FACILITY FEE+I TANK- (snO)X(aenks) ($n0)X(mnks)- - - - - - - _ <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 /> CLOS;d_-k _.__ <br /> Removal orPemdtted-Closure in Place .. - . . .. .. <br /> $ <br /> TANK ID it(s): CLOSURE FEE=.5279/,TANK #TANKS X$279= __ <br /> TEMPORARY CLOSURE - - - <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279./FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan a.:k and Constrjclion Inspec!ons) <br /> .—_.. <br /> i TANK ID# s): f PLAN CHECK FEE_.$7441 FACILITY $ <br /> REPAIR PLAN CHECK - - <br /> i <br /> i <br /> TANK ID#(s): _ q <br /> TANK.RETROFIT REPAIR FEE _$279/FACILITY (use for monilming equipment,spill buckets•tank sumps.mist.) I•. I <br /> $ <br /> PIPING REPAIR FEE =$279/FACILITY (use for piping;under-disperiser containment ecL) <br /> MISCELLANEOUS <br /> I <br /> $ <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $931 HOUR $ <br /> SAMPLING INSPECTION FEE _ $93/HOUR - -. <br /> $ <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# 1 FACILITY ID AMOUNT RECEIVED>` CHECK# ' -1 RECENED BY I DATE RECENED <br /> SR <br /> EH 23032(REVISED 8101103) <br />