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SAN JO IN COUNTY ENVIRONMENTAL HEALTH DW&RTMENT <br /> UNDERGROU'RD STORAGE TANK PROGRAM FMFWORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRES� SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA q O�)q, <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(Aanks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED I i <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 X$279= $ <br /> TEMPORARY CLOSURE <br /> I (Plan Review and Inspections) <br /> ANK ID#(s): TEMPORARY CLOSURE FEE $279 FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> LAW"ID#(s): PLAN CHECK FEE $744 FACILIT`V $ <br /> REPAIR PLAN CHECK <br /> T <br /> ANIK ID#(s): <br /> TANK RETROFIT REPAIR FEE $279 FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) $ <br /> PIPING REPAIR FEE $279/FACILITY (use for piping,under-dispenser containment,ect) <br /> MiSCELLANEOUS, <br /> i RANSFER FEE $20 $ <br /> CONSULTATION FEE $931 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE $93 HOUR <br /> SAMPLING INSPECTION FEE $93V 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 /> SERVICE REQUEST# 71FACILITY ID I-AMOUNT RECEIVED CHECK RECEIVED_#_ T BY DATE RECEIVED <br /> SIR I I <br /> EH 23 032(REVISED 8/01/03) <br />