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SAN Jr 'QUIN COUNTY ENVIRONMENTAL HEALTH r--'ARTMENT <br /> UNDERGRC JD STORAGE TANK PROGRAM f - WORKSHEET <br /> FACILITY NAME FA �I/TY C2NTACT NAME <br /> FAC LI ADDRESS SITE P NE#WITH AREA CODE <br /> 9 c23 - _3 <br /> CITY L STATE ZIP CODE #OF TANKS AT SITE <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 STATE ZIP CODECIRCLE WORK TO BE DONE: <br /> S TOCKTON CA 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEF INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks) ($no)X(#tanks) <br /> $125 PER TANK AFTER FIRST TANK — <br /> m <br /> TANK PENALTY ASSESSED <br /> - ---- 1- $ ----� <br /> i <br /> h+JK SURCHARGE=$1n/TANK -- —-_- —- _ - <br /> STATE SURChAkGE t"_ ,FACILIi IES NO ALR+=F,JY ON INVENTORY IN A CUPA PROGRA_'_ 417.50/FACILITY <br /> PERMANENT CLOSURE - <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> iTEMPuRARY CLOSURE <br /> (Pian Review and Insp_ f,ns) <br /> TANK IU#(s)` — <br /> TEMPORAF<Y CLOSURE FEE_!279%FACILII Y" <br /> (Plan Chef*and �;nstruction Insoections) <br /> -_—`_-- PLAN Cl-'r-CK FEE=$744/FACILITY <br /> REk'>iR PLAN CHECK - - -.-.-- <br /> TANK R_E?RCFIT REPAIR FEE _$279/FACILITY (Use for monitoring e,_jipi,.ant,spill buckets,rank sumps,mist.) $ �- I <br /> kPiNG REPAIR FEE =$279/FF.CILITY (.ise for piping,under-dts,,neer cantain;nent,Pct.' $ <br /> 'il`.�ELLANEOUS --- ---- -- - --- ----- - -----.-� <br /> R-�NSFER FEE _ $20 <br /> } <br /> L,ONSULTATION FEE--—$93/HOUR - _ -- - -— --- -- - t <br /> UNAU71ORIZi:D RELEASE EVAL•u'.AT!)N FEE = $'-�3 r HOutZ _— -- -'_ <br /> SAMPLING INSPECTION FEE _ $93/HOUR $ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. ME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE Rt-QUEST# FACILITY ID ! AMOUNT RECEIVED-� CH�.,;I;# RECEIVED BY DATE RECF,;.IED <br /> SR <br /> EH 23 032(REVISED 8101/03) <br />