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SAN., 'QUIN COUNTY ENVIRONMENTAL HEALTH D RTMENT UNDERGR&oND STORAGE TANK PROGRAM Flt✓WORKSHEET FACT AM FAI[ 11TY CONTACT NAME FA KESS S PH EA CODE CffY STATE Z P CODE S OF TANKS AT SITE CA APPLICANT BRlING NAME APPLICANT CONTACT NAME ELITE IV CONTRACTORS, INC. CARRIE MILLER APPUGM I MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE 2535 WIGWAM DRIVE 209) 461-6337 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: STOCKTON CA 95205 Gosure Instalation Repair Retrofit ACTIVE FACILITY 6 $SOGFEEINCLUDES FACILITYFEE 4 1 TnNfl< 1998 1999 2000 2D01 2002 - - 5:199 tmanks) 1117otxiYbdd) _. i $125 PER TANK AFTER FIRST TANK -- [TANK NALTY ASSESSED $ RCHARGE_$10/TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$17.50/FACIUTY $ PERINANENT CLOSURE Rem0v 1 ar.P- tted Closure in Place). TANK ID#LsCLOSURE FEE_$279/TANK #TANKS X$279= $ TEMPORARYCLOSURE - (Plan Review and Inspections) TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY $ INSTALI,ATKNLPLAN CHECK (Plan Check and Construction Inspections) - TANK ID#(s): PLAN CHECK FEE_$7441 FACILITY $ - REPAIR PLAN CHECK TANK ID# LS : $ TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mist.) - PIPING REPAIR FEE _$279/FACILITY- (use for ipin9,underdis er containment.ect - $ iiMISCELLANEWS- � i TRANSFER FEE _ $20 Is 1 - CONSULTATION FEE _ $931 HOUR $ UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR - $ 7 � SAMPLING INSPECTION FEE _ $931 HOUR $ j ALL FEES ARE BASED ON THE 593 HOURLY RATE. TIME THAT IXCEEDS FEES PAID VML BE WI(Fn TO OFFICE T- OFFICE USE ONLY i SERVICE REQUEST i' FACILITY m AMOUtiT RECENED:- CHECK# RECEIVED BY DATE RECENED - SR EH 23 032(REVISED 8101103)