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SAN JO' -UIN COUNTY ENVIRONMENTAL HEALTH Dr \RTMENT <br /> UNDERGROLL`-.D STORAGE TANK PROGRAM FL---,I WORKSHEET <br /> FACILI NAME FACIM CONTACT NAME <br /> 'l u 6YL U <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 77 i -63 Q <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> C[ CA 9 �37L <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 I 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 /> $509 FEE INCLUDES FACILITY FEE+I TANK ($170)Xrftm6) ($no)X(Rams) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TAI,*;;PENALTY ASSESSED _ a <br /> T!NK SURCHARGE=$10/TANK _ _ _ $ <br /> j—STATc SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> PERMANENTCLOSURE <br /> (Ftenlovai or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Rcview and Inspections) <br /> — .. _. _ <br /> $ <br /> LT <br /> _ EIvP;FURY CLOSURE FEE_$279/FACILITY , <br /> "r.15TALLATION PLAN CHECK <br /> ' - -in CG; X ana Constru:tion Inspections) <br /> - --- 1-- $ --; <br /> TA NK IU#(s)' !PLAN CHECK FEE=$744/FACILITY <br /> REPAIn ;LAN CHECK <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment,spill bud(ets,tank sumps,mist.) P- <br /> I $ <br /> PIPING REPAIR FEE _$279/FACILITY use for Piping,under-dispenser comarnment,ect). <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 '-- $. _ <br /> CONSULTATION FEE _ $93/HOUR $ <br /> UNAU_1 HORIZED RELEASE EVALUATION FEE = $9;:/HOi'f:_ __ <br /> I <br /> SAMPLING 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 <br /> E REQUEST# FACRJTY ID AMOUNT RECEIVED - Ci;ECK# RECEIVES <br /> SRI BY DATE RECEIVED <br /> EH 23032(REVISED 9/01103) T <br />