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SAN UIN COUNTY ENVIRONMENTAL HEALTH DfTMENT <br /> UNDERGR D STORAGE TANK PROGRAM FEE WORKSHEET <br /> �FAXCILFTY <br /> FACILITY NAME FACILfTY CONTACT NAME <br /> ADDRESS SITE PHONE#WiTH AREA CODE <br /> CIl 1f TATE ZIP CODE #OF TANKS AT SITE <br /> � t CA <br /> M 2 <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 =CIRCLEWORK TO BE DONE: <br /> STOCKTON CA 95205 allation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 -2001 2002 20..03_ <br /> $5Q0 FEE,INCL4QES FAC!!`IT1�FEE+-i TANK- tlSan <br /> (st.o X ks <br /> $125 PER TANK AFTER FIRST TANK - <br /> I $ <br /> 3 TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$301 TANK $ —Y <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.501 FACILITY � <br /> PERMANENT CLOSURE - ---) <br /> Removal or PEN nutted Closure i:,I}lace <br /> TAMC ID 17(s): CLOSURE FEE=$2791 TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): I TEMPORARY CLOSURE FEE=$279/FACILITY $ <br /> INSTALLATION PLAN CHECK - -- <br /> (Plan Check and Construction Inspection-) <br /> TANK ID#(s) PLAN CHECK FEE_$7441 FACILITY <br /> REPAIR PLAN CHECK - <br /> TANK ID 4 s) <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank_sumps,mL-A;,) ? I <br /> $ s <br /> PIPING REPAIR FEE _$279!FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS --� <br /> TRANSFER FEE $20 - $ I <br /> CONSULTATION FEE _ $931 HOUR $ i <br /> UNALFTHORIZED RELEASE EVALUATION FEE _ $931 HOUR $ <br /> SAMPLING INSPECTION FEE _ $931 HOUR $ j <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE.. TIME THAT E)ICEE01 FEES—PA-0—WELL—BE BILLED TO APPLICANT. <br /> OFIRCE USE ONLY <br /> i <br /> SERVICE REQUEST 0 FACILITY ID AMOUNT RECEIVED CHECK# RECEIVEb BY DATE RECEIVED <br /> SRIEH 23 032(RLI/tSEO 8101103) <br /> I I <br />