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SAN 4&UIN COUNTY ENVIRONMENTAL HEALTHRTMENT <br /> UNDERGRMND STORAGE TANK PROGRAM c- WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE f WITH AREA CODE <br /> - 1639 <br /> CITY TSTATE ZIP CODE #OF TANKS AT SITE <br /> I 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 I 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) (5170)x(#tanks) <br /> $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 /> PERMANENT CLOSUR <br /> i�RemoA1 or Permitted Closure in Place) <br /> I 'O` NK ID#(s): CLOSURE FEE=$279/'TANK #TANKS X$279 <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): --TTEMPORARY CLOSURE FEE=$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): � $ <br /> PLAN CHECK FEE_$744/FACILITY <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,misc. <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY use for piping;under-dispenser containment,ect <br /> I <br /> MISCELLANEOUS. I <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $931 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR $ <br /> SAMPLING INSPECTION FEE _ $93/HOUR F� <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# I FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8/01/03) <br />