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SAN Jr'- `UIN COUNTY ENVIRONMENTAL HEALTH C^-4RTMENT <br /> UNDERGRC _D STORAGE TANK PROGRAM F . WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> rl n 1 E r V 1 <br /> FACILITY ADDRESS SITE PHONE#WITU AREA COD <br /> ?� - <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> In(,,,I I tq- a <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 CALi 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(#tanks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED <br /> !hNK SU%cOHARGE=$10/TANK — <br /> STATE SU%!-,'LARGE FOR FAC; 'TIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/ ACli:: $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Insrections) <br /> TANK ID#(s): — - — -- TEMPORARY CLOSURE FL-L _$279/FAGIL_i F.- -.-1$ <br /> INSTALLATION PLAN CHECK <br /> n Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/PACILITY $ <br /> REPAIR PLAN CHECK—-- ----— — _.-- --._-� <br /> i <br /> TANK ID# s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,miscue— <br /> i PIPING REPAIR FEE =$279/FACILITY — (use for piping,sunder-dispenser containMent,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 <br /> - g <br /> CONSULTATION FEE _ $9:1t HOUR _ <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $:i3/HOUR <br /> SAMPLING INSPECTION FEE _ $93/}-TOUR _ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME TL-IAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVER <br /> SR <br /> EH 23 032(REVISED 8/01/03) <br />