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SAN UIN COUNTY ENVIRONMENTAL HEALTH RTMENT <br /> UNDERGR ND STORAGE TANK PROGRAM WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> x\ IF, 1,5- <br /> CITY <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> L CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ELITE IV CONTRACTORS, INC. <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(Aanks) ($170)X(#tanks) <br /> I $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> n 'PF M ANENT CI OSURE <br /> (Removal or Permitted Closure in Place) <br /> i TANK ID#(s): CLOSURE FEE=$27911'TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Re; iew and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN 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 /> $ <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under4s enser containment,ect.) <br /> I <br /> MISCELLANEOUS. . <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR <br /> $ c <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. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SIR <br /> EH 23 032(REVISED 8/01/03) <br />