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SAN JOAQUINc,,,.;(Y PUBLIC HEALTH SERVICES-ENVIRONMEI04L HEALTH DIVISION <br /> UNDERGROrJND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAM <br /> FA ILIiY CONTACT NAME <br /> 7PyACILfrY ADDR SS SITE PHONE#WITH AREA CODE <br /> lX33/ 7$�j <br /> CITYAOU STATE ZiP CODE <br /> #OF TANKS AT SITE <br /> CA ' <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ELITE IV CONT ACTO S INC. <br /> APPLICANT MA1lNiG ADDRESS LICANT PHO E#WTTH AREA CODE <br /> 2535 WIGWAM DRIVE <br /> Cm STA rE 209 461 -6337 <br /> ZIP CODE CIRCLE WORK TO BE DONEE <br /> STOCKTON CA 95205 <br /> Clowre InstaKabon Repair Retrofit <br /> ACTIVE FACILITY - _ -- - - <br /> 1996—1999 2000 12001 1 <br /> $500 FEE INCLUDES FACILITY FEE+ 1 TANK tit7c)xPpnF!s)X 0=yeas appszab;e --- <br /> S1.25 rER TANK AFTER FIRST TANK <br /> t 1 <br /> TANK PENAL-.f ASSESSED <br /> TANK SURCHARGE=$8/TANK $ <br /> STATE SURCHARGE FOR FACILffIES NOT ALREADY ON INVENT $ <br /> ORY IN A CUPA PROGRAM-=S10/FACIUTY <br /> i <br /> PFJT111AtENT CLOSURE - <br /> Renxwal or Pemutted Cbsure in Pla <br /> '- TEMPORARY CLOSURE <br /> CLOSUREFEE=$267/TANK 4 TANKS X$267= $ <br /> (Rml Reuew and Inspechi ) <br /> .APD(ID i(s): TEMPORARY CLOSURE FEE- ---! - <br /> !FACILITY $ I <br /> INSTALLATION PLAN CHECK —' <br /> n Check and Constructirn Inspe�orLs) <br /> TANK ID 4(s): PLAN CHECK FEE_$712/FACILITY $ <br /> REPAIR PLAN CHECK - <br /> i <br /> TANK ID;#(s): <br /> TANK LINING REPAIR FEE _$267!TANK $ <br /> 4 TANKS X$267- <br /> TANK RETROFIT REPAIR FEE =$267/FAaUTy $ <br /> PIPING REPAIR FEE _$267/FACILITY $ <br /> MISCELLANEOUS ' f <br /> TRANSFER FEE = $20 ! j <br /> $ <br /> CONSULTATION FEE = Saw HOUR $ <br /> i <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 39/HOUR $ _ <br /> 1 <br /> SAMPLING INSPECTION FEE = S SW HOUR $ <br /> ALL FEES ARE BASED ON TME Ue9 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY 1 <br /> SERVICE REQUEST s FAGILfiY ip AMOUNT(iECENED - } f <br /> CHECK i RECEIVED BY DATE REGENED <br /> EH n 032(REVISED 8A-0tf I 1. <br />