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- AL, X �- <br /> SAN J, UIN COUNTY ENVIRONMENTAL HEALTH f 'kRTMENT 0�4 ' <br /> UNDERGRC JD STORAGE TANK PROGRAM f . WORKSHEET <br /> FA ITY NAME FA ,CONTACT NAME <br /> FACtLITY ADDR % SITE PHON E#WITH AR CO E <br /> CI I STATE ZICP�CO�DE #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 ( 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 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks) ($170)X(Manks) <br /> $125 PER TANK AFTER FIRST TANK -- <br /> TANK PENALTY ASSESSED <br /> w <br /> TANK SURCHARGE=$10/TANK <br /> STATE SURCHARGE,';`?_ FACILIT iES NOT ALREADY ON IWIENTORY IN A CUPA PROGRAM=`vD i 1.50/FAUil.;TY �- <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 Inspe .tt^ s) <br /> TANK ID#(s):_ TF_MPOF2AR 'CLOSURE FEE_$279 IIs AL i ' ! <br /> INSTALLATION Pt A(J CHECK - -_ -- ---- -- <br /> Plan Check and Cc trucbor.Inspections) <br /> TANK ID#(s): —_ -^ -—-� -- PLAN CHE�-K FEE_$744/FACILITY— $ ^---! <br /> r REPAIR PLAN CH2.CK -- -` —- — ---- <br /> I <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.)� $� <br /> PIPING REPAIR FEE _$279/FACILITYng <br /> use for r $ <br /> ( piping,,�rnder{iisper:ser containment,ert) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ _ $93/HOUR - --- - ---- $ -_ _ <br /> is i <br /> UNAUTHORIZED RELEASE EVALUATIGN'FEE _ $93/HOUR_ <br /> SAIAPLING 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 <br /> SERVICE REO VEST# FAC ITY ID AMOUNT RECEIVED CHECK# RE-Z--TCEIVEf BY DATE RECE!bFD <br /> SR <br /> EH 23 032(REVISED 8/01/03) <br />