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SAN Jj&UIN COUNTY ENVIRONMENTAL HEALTH DTMENT <br />UNDERGRO D STORAGE TANK PROGRAM FE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />EAPPLICANTMAILING ADDRESS <br />APPLICANT PHONE #WITH AREA CODE <br />WIGWAM DRIVE <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR <br />FACIL ADDRESS <br />SITE PHONE # WITH AREA CODE <br />s •.� <br />_ <br />CITYSTATE <br />ZIP CODE # OF TANKS AT SITE <br />CA <br />�. <br />TANK PENALTY ASSESSED <br />A. -I 1r.— nn . <br />E IV CONTRACTORS, INC. <br />APPLICANT CONTACT NAME <br />CARRIE MILLER <br />EAPPLICANTMAILING ADDRESS <br />APPLICANT PHONE #WITH AREA CODE <br />WIGWAM DRIVE <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR <br />$ <br />9) 461-6337 <br />$ <br />CODE CIRCLE WORK TO BE DONE_ <br />=STATEZIP <br />STOCKTON <br />95205 <br />Closure Installation Repair Retrofit <br />FACTIVE FACILITY <br />_-- 1998 1999_ 2000 7001 2002. 2003.. EEFiNGLUES FAGILiTY FEE a-1 TA,°JK (si7 <br />$125 PER TANK AFTER FIRST TANK <br />o)xlrta�ks) <br />(siiolximarj <br />$ <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR <br />$ <br />ON FEE _ $ 93/ HOUR <br />THE iV3 Nnt�cae Y cert nR6C TV AT CV/C�.•[ <br />$ <br />$ <br />TANK 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 />(Plan Check and Construction Inspections) <br />TANK ID # (s) <br />REPAIR PLAN CHECK <br />[TANK <br />ANK ID #S) <br />RETROFIT REPAIR FEE _ $279 /FACILITY (use for <br />PING REPAIR FEE = $279 /FACILITY (use for <br />PLAN CHECK FEE _ $744 / FACILITY <br />tank sumps, misc.) $ <br />ecL) <br />MISCELLANEOUS --� <br />AMOUNT RECEIVED CHECK RECEIVED BY <br />TRANSFER FEE = $ 20 <br />— <br />---, --- -.. <br />CONSULTATION FEE _ $ 93/ HOUR — <br />$ <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR <br />$ <br />ON FEE _ $ 93/ HOUR <br />THE iV3 Nnt�cae Y cert nR6C TV AT CV/C�.•[ <br />$ <br />SAMPLING INSPEGTI <br />ALL FEES -ARE BASED ON <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY tD <br />AMOUNT RECEIVED CHECK RECEIVED BY <br />DATE:RECEIVED <br />SR <br />EH 23 032 (REVLSEn s/mins► <br />