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SAN J( JIN COUNTY ENVIRONMENTAL HEALTH DE ;TMENT <br />UNDERGROVI4D STORAGE TANK PROGRAM FEc WORKSHEET <br />F -M- -1 IT NAMt <br />FACT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />T <br />FACILITY ADDRESS <br />SITE E # WITH AREA CODE <br />/� <br />I � & A ka ' <br />CITY ST E <br />Z� i <br />ZIP CODE # OF TANKS AT SITE <br />2535 WIGWAM DRIVE <br />CA <br />CI -15 '764 <br />(209) 461-6337 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />(209) 461-6337 <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />STOCKTON CA <br />95205 <br />Closure Installation Repair Retrofit <br />ACTIVE <br />1998 1999. 20002001 201 - O�OD3 <br />;500 F.EEINCr_UDES FACILITY FEE , 1 T, st:Gi> ;;;,nks) is.-1olxownks) <br />I $125 PER TANK AFTER FIRST TANK - r-- <br />�$ <br />TAA NK PENALTY ASSESSED <br />TANK SURCHARCi= = $10 i TANK — <br />STATE SURCHARGE FOR FAC1LtTi1= i .f2E_ADY ON GdVENTf?RY IN A CUPA PROGRAM 417.5.;/ F.vi'' .i ! •' r <br />PERMANENT CLOSURE — - --� <br />Removal or Permittee ::losur. in Pfacej_ r <br />TANK ID # (s). CLOSURE FEE = $279 / TAN:c+ # TF.rtKS x $27a = $ <br />TFMIPORARYCLOSURE — - — �-.___----_.- <br />(P.an Review and Ins ,,"tions) <br />TANK ID # (s) : j i F_Mi ORARY CLOSURE FEE = $279 / FACILITY j <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : PLAN CHECK FEE = $744 / FACILITY $ <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use fur monitoring equipment pill buckets tank sL•rn misk: ) <br />PIPING REPAIR FEE = $279 / FACILITY <br />MISCELLANEOUS <br />.ANSFER FFF <br />JONSULTATION FEE _ $ 93/ HOUR <br />(use for piping, under -dispenser conainment, ecL) , <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 EXCEE <br />k;EnvICE RL -QUEST # , FACWTY ID AMOUNT REC <br />SR <br />EH 23 032 (REVISED 8/01/03) <br />FEES PAID WILL BE BILLED TO /4'.'=5CANT. .I <br />lit <br />'En _ wart #_ RECE /ED BY DATE RECEIVED <br />I� <br />�i <br />�I <br />