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SAN A JIN COUNTY ENVIRONMENTAL HEALTH DE ZTMENT <br /> UNDERGROVL4D STORAGE TANK PROGRAM FEL_ WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> e- Go <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 9's-6& Wci ( U cb '--I 6.S - 14 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA 153 <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 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 /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x(#tanks) ($170)x(#nada) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS k$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): PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) $17 <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ect.) <br /> MISCELLANEOUS I <br /> — - - - $ <br /> CONSULTATION FEE _ $93/HOUR _ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR <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 /> fSE,RVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED i <br /> EN 23 032(REVISED 8101/03) <br />