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,A '-IOAOUIN COUNTY EWRONMEtENTAL HEALTH DEPf.RTMENT <br />UNDERGROUND STORAGE TASK PROGRAM FEE WORKSHEET <br />APPLICANT BILLING NAME <br />FACILITY CONTACT NAMEMrr <br />FLIT£ IV CONTRACTORS, 'INC <br />W 0. "1 {� (5 (JRESS <br />APPUCANT MAILING ADDRESS - <br />SITE PHONE S WITH AREA CODE <br />FFACrLf-SYE <br />- ter GcWc; <br />a4 q 93-1 � <br />CITY <br />STATE <br />ZIP CODE <br />it OF TANKS AT SITE <br />%a N <br />CA <br />� u� v`� <br />APPLICANT BILLING NAME <br />-APPLICANT CONTACT NAME <br />FLIT£ IV CONTRACTORS, 'INC <br />CARRIE-MILLER. <br />APPUCANT MAILING ADDRESS - <br />APPLICANT PHONE 9 WITH AREA CODE <br />2535. WIGWAM DRIVE <br />209) .461-6337. <br />CITY <br />STATE <br />ZIP CODE- <br />CIRCLE WORK 70 BE DONEE <br />Closcue Insta@ation Repair Retrofit <br />SiOCiCTvri <br />CA- <br />1.95205 <br />ACTIVE FACILITY <br />TANK ID S (s) :. CLOSURE FEE =-$279 YTANK <br /># TANKS X 5279 = <br />1998 <br />1999. <br />2000 <br />2001.2002 <br />2003- <br />$500 FEE INCLUDES FACILITY FEE :& 1 TANK - <br />. ciao) x p-," <br />g70).x t ­*1 <br />UNAUTHORLZED RELEASE EVALUATION FEE_ = S 931 HOUR . <br />- <br />( $125.PER TAW AFTER FIRST TAW <br />$ <br />TAMC PEMALTYASSESSED <br />- <br />$ <br />TANK SURCHARGE = $101 TAW <br />$ <br />STATE SURCHARGE FOR FAC>t fi IES NOT ALREADY ON INVENTORY INA CUPA PROGRAM =$17.5W FACILITY <br />i - rr- J15 iiAtQENT CLOSUkE " <br />(PeawwWorPeffnittedCk3surein-PL-&ce"- - - - <br />TANK ID S (s) :. CLOSURE FEE =-$279 YTANK <br /># TANKS X 5279 = <br />TEMPORARY CLOSURE <br />(Plans Review and 1a5,-pec5ms) <br />TANK ID .# (s): <br />TaPORARY CLOSURE FEE= $279"I FACILITY . <br />- HZSTALJLATION PLAN CHECK - <br />(Ptar► Check and Cocrstruc6on I-nspections) . _. <br />TANK ID;; (s) : PLAN CHECK -FEE =.$7441 FACILITY <br />REPAIR PLAN CHECK <br />TANK ID 9 (s): <br />TANKRETRORT REPAIR FEE _ $2791 FACfUTY (use %x ffmb ing equipiaenL spM buckets_ tank sumps. rd—) Q <br />PIPENiGREPAIR FEE _ $279 / FACILITY (use torp .-ki �speiiser cai>tairuneni eci) _ _ + 7 S, . <br />-- - <br />IJUSCELLANEOUS ---- <br />TRANSFER FEE _ $ 20 <br />"CONSULTATION FEE : = $ 931 HOUR <br />UNAUTHORLZED RELEASE EVALUATION FEE_ = S 931 HOUR . <br />SAMPLRdG fi&--�EG710N FEE _ $ 931 i 101 R <br />.I <br />. s <br />- i <br />r <br />ALL FEES'ARE BAS®ON THE S43 HOURLY RA7E_ ME THAT EXC®S FEES PAID WILL BE BfILED TO APKJCAK I _ <br />OFFICE USE ONLY i <br />