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SAN ,QUIN COUNTY ENVIRONMENTAL HEALTH I �RTMENT <br /> UNDERGRuiND STORAGE TANK PROGRAM FtL WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS U SITE PHONE#WqrH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <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 /> S TOCKTON CA 9 5 20 5 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 1 ANK ($170)x(l twks) (S 170)x(manks) <br /> $1 6 PER TANK AFTER FIRST TANK — -- <br /> i $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$10/TANK <br /> S-rATESURCHARGE FOR FACILITIES NOT ALr:EADY ON INVEWOR f INH CUPA PROGRAM=$17.50/FkU;ILI-Y $ <br /> PERNIMENT C?OSUR _ --- --- <br /> ,Removal or Pernitted Closure in Place) <br /> j TANK ID#(s): j CLO(r IJRE FEE_$2.79/'TANK #TANKS X$279= j <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$=79/FACILi I Y <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#I s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID t/(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use f monitoring equipment,spill buckets,tank sumps,misc.) i L J <br /> PIPING REPAIR FEE _$2791 FACILITY (use fir! piping,under-dispenser containmen� ecL) I $ I <br /> MISCELLANEOUS <br /> 4 $ <br /> TRANSFER FEE _ $20 _ <br /> CONSULTATION FEE _ $93/HOUR <br /> i <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR _ <br /> r <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. i <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# tjACWTy ID AMOUNT RECEIVED CHECK# I RECEIVED BY DATE RECEIvED <br /> SR <br /> EH 23 032(REVISED 8/01/03) <br />