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SAN QUIN COUNTY ENVIRONMENTAL HEALTH L ARTMENT <br />UNDERGRuiND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />FAC-1frTY AD RESS <br />SITE PHONE # WITH AREA CODE <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 f HOUR <br />(209) 461-6337 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />Closure Installation Repair Retrofit <br />r <br />CA <br />i <br />$ <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />+ �` _ -• - <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 f HOUR <br />(209) 461-6337 <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />TON <br />STOCKCA <br />95205 <br />Closure Installation Repair Retrofit <br />PFRMANENT CLOSURE --- ---, <br />Renr.;,.dl or PerrniVed Ciwure in Pias) <br />TANK ID # (s) : CLOSURE FEE = $2.79 / TANK # TANKS X $279 = $ <br />TEMPORARY CLOSURE -- — <br />(Plan Review and Inspections) <br />TANK ID # (s) : TEMPORARY CLOSURE FEE _ $279 / FACILITY $ <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : $ <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />498 <br />:.-r e Fs=F= lfx(a=iJDF F C!LITY FEr + 1 TANK O -POI X �4tanks) <br />1 $125 C'ER TANK AFTER FIRST TANK <br />I <br />I 1999 12000--T-001 <br />i7; B) X Mans' <br />12002 <br />) <br />200: <br />__ <br />$ <br />+ �` _ -• - <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 f HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$ <br />T&JK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $10 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />$ <br />PFRMANENT CLOSURE --- ---, <br />Renr.;,.dl or PerrniVed Ciwure in Pias) <br />TANK ID # (s) : CLOSURE FEE = $2.79 / TANK # TANKS X $279 = $ <br />TEMPORARY CLOSURE -- — <br />(Plan Review and Inspections) <br />TANK ID # (s) : TEMPORARY CLOSURE FEE _ $279 / FACILITY $ <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : $ <br />PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />i <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use fa- monitoring equipment, spill buckets, tank sumps, misc.) <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$D:lq <br />$ <br />MISCELLANEOUS —, <br />ANS,FER FEF - ? ?(1 <br />i <br />-_ - ---_ - - - --- --- — _-_' - <br />, <br />CONSULTATION FEE _ $ 93/ HOUR <br />+ �` _ -• - <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 f HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$ <br />ALL FEES ARE BASED ON THF SQ -4 Nnt IRI V V ATC TMC <br />OFFICE USE ONLY <br />SERVICE REQUEST>a: FACILJTY <br />SR <br />EH 23 032 (REVISED 8/01/031 <br />RECEIVED I CHECK x TRECFEWED BY I DATE <br />