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J <br />SAN JJMUIN COUNTY ENVIRONMENTAL HEALTH Dq&TMENT <br />UNDERGROWD STORAGE TANK PROGRAM FEW -WORKSHEET <br />FACT TY NAME c,, <br />APPLICANT CONTACT NAME <br />FACIVTtf CONTACT NAME <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />FACILITY ADDRESS <br />CITY <br />SITE Pp ONE # AREA CODE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />STOCKTON <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />$125 PER TANK AFTER FIRST TANK <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />(209) 461-6337 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />STOCKTON <br />CA <br />95205 <br />ACTIVE FACILITY <br />TANK ID 4 (s) : <br />CLOSURE FEE _ $279 / TANK <br />1998 <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />($»o) X (#tanks) <br />($no)X (#tanks) <br />$125 PER TANK AFTER FIRST TANK <br />TANK PENALTY ASSESSED <br />TANK SU RCHARGE = $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 4 (s) : <br />CLOSURE FEE _ $279 / TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : _ <br />TEMPORARY CLOSURE FEE _ $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : . <br />IPLAN 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.) <br />c;t <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect-) <br />MISCELLANEOUS <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL rttJ HKr CSHJGt7 VN MM $y3 nVUKLT KAI C. I Wr 1 HAI r-AI.C.CUJ rCCJ rAalJ VVILL 6C MILL -CU Iv Arrut.Ary I. _ <br />OFFICE USE ONLY <br />SERVICE REQUEST # I FACIUTY ID AMOUNT RECEIVED CHECK # RECEIVED BY I DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 8/01/03) <br />