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SAAQUIN COUNTY ENVIRONMENTAL HEALTH ATMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACTS NAME _ FACAM CONTACT NAME <br /> cc /e <br /> FACILITY ADDRESS _ SITE PHONE S WfTH AR coo <br /> I D 9 <br /> CITY STATE 23?CODE S OF TANKS AT SITE <br /> R <br /> 8 l00/� To Ai CA �S� / z /= vo /z <br /> APPLICANT BR.UNG NAME - - - APPLICANT CONTACT NAME ' <br /> ELITE IV CONTRACTORS, INC_ CARRZE MILLER <br /> - APPLICANT MAILING ADDRESS APPLICANT PHONE S WITH AREA CODE <br /> 2535 ,WIGWAM DRIVE ( 209) .461-6337 <br /> CRY STATE ZIPCODE- CIRCLEWORK TO BE DONE <br /> STOCR1VLt CE1 95201 gosure Instaeation Reptiv Retrofit <br /> _ - .ACTIVE FACQ7N � � <br /> 1998 1999- 2000 2001 2002 2003 <br /> _ <br /> $AO FEEINCLUDES fACIL1TYFEE-I TANK.. gnHxlm q IsnoLx<mvavl <br /> ( $125.PER TAMC AFTER RRSTTANK <br /> ' TANK PENALTYASSESSED <br /> TANK SURCHARGE $10 TANK <br /> STATE SURCHARGE FOR FAcunES NOT ALREADY ON M MORY IN A CUPA PROGRAM 417.W FACILRY <br /> -.. -.,.•-....,,. -)-PEILGTANENT CLOSURE ... ._ . -.. - - . <br /> for PemWted Cbsurem Place <br /> TANK ID S(s) - CLOSURE FEE=$279 YTANK S TANKS X 5279= - --- - <br /> TEMPORARY CLOSURE - - - - - - <br /> Wil Review and hyo ) _ $ <br /> TANK IDI(s)- TEKPORARY CLOSURE FEE=$279J FACILITY . <br /> ' INS-TALLATION PLAN CHECK . <br /> (Ptah Check and ConstrurS Ls.L-ctions). - •._, <br /> TANK IDi(s)- PLAN CHECK FEE-S744I FACILITY - <br /> . REPAIR PLAN CHECK <br /> I <br /> TANK IDS(s): <br /> TANK.RETROFR REPAIR FEE _$279!FACIL)T1' (use for ffwAormg egtfpm L sptT buckets.tank sumps,m6c) <br /> $ - <br /> PIPINGFLEPAIR FEE =$279/FACILITY (use farpip"vrAurdeidsperae<contaMnwnl ed) - 1 <br /> MISCELLANEOUS. <br /> TRANSFER FEE = S2f1 - <br /> "CONSULTATION ISE : _ $931 HOUR <br /> IRdAUTHORiZED RELEASE EVALUATION FEE . = S 931 HOUR <br /> $ i <br /> SAMPLING WSPECTION Ftp = 5 93/HOUR <br /> . = plIF17=S"p(tE gASm ON THE$93HCURLYRATE TWETHAT E%C®SFEES PAID WLLL BE R"I TOAPPLW-W- _ <br /> OFFICE USE ONLY j. <br /> . . SERVICEREQUESTs - I FAC@ITYID I AMOtMTRtUV] :: C11ECKa ' j RECENEDBY I OATEN 47— <br /> `. <br />