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SAN Jr . -)UIN COUNTY ENVIRONMENTAL HEALTH Dr- NRTMENT UNDERGRC 1D STORAGE TANK PROGRAM F. . WORKSHEET rs��,ru r r nAMt FACILITY CONTACT NAME �L` �'�' ` Y 1 1\ APPLICANT MAILING ADDRESS SITEPHONE # WITH AREA CODE PFACI�LITYADDI,REgS CvCC,Cve+; U STATE ZIP CO E # OF TANKS AT SITE C-\ 1 CA '�` 2 ! Ci c� ` 1zIP CODE CIRCLE WORK TO BE DONE: APPLICANT BILLING NAME APPLICANT CONTACT NAME ELITE IV CONTRACTORS, INC. CARRIE MILLER APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2535 WIGWAM DRIVE $ $ (209) 461-6337 CITY STATE 1zIP CODE CIRCLE WORK TO BE DONE: STOCKTON CA 95205 $ Closure Installation Repair Retrofit ACTIVE FACILITY $500 FEE INCLUDFS FA.C!LITY FEE + 1 TANK $125 PER TANK AFTER FIRST TANK 1998 ($no) x (wanks) 1999 ($170) x (wanks) 2000 2001 2002 2003 $ $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $10 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY $ PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s) : CLOSURE FEE = $279 / TANK # TANKS X $279 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY INSTALLATION PLAN CHEC (Plan Check and Construction I TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY I $ REPAIR PLAN CHECK TANK ID # (s) : $ $ TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) $) / C PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) $ MISCELLANEOUS - TRANSFER FEE _ $ 20 $ $ CONSULTATION FEE _ $ 93/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR $ SAMPLING INSPECTION FEE = $ 93/ HOUR ALL FEES ARF RASFn CIN TUF taa unt io1 v n Ar. -1 r --------- $ .. - - — •----- - — OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED ISR EH 23 032 (REVISED 8/01/03)