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• SAN J' )UIN COUNTY ENVIRONMENTAL HEALTH C ',RTMENT <br /> UNDERGRG-AD STORAGE TANK PROGRAM FL_` WORKSHEET <br /> WFNAME FACILITY CONTACT NAME <br /> , <br /> ADDRESS SITE PPHONE#WITH ARREA CODE <br /> CD I STATE X 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 /> ( 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 19992000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks) ($170)X(#tanks) <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 /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY_ 1� <br /> INSTALLATION PLAN CHECK —" <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): I:J� PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): n <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) $ -77 <br /> PIPING REPAIR FEE =$2791 FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS I .I <br /> ' I <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $93/HOUR <br /> I <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 EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY l <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8/01/03) <br />