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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DE&JRTMENT <br /> } UNDERGRO D STORAGE TANK PROGRAM F WORKSHEET <br /> FACT ITY NAME FACILITY ONTACT NAME <br /> FACILITY ADDRESS SITE PHON #WITH AREA CODE <br /> CITY TSTATE ZIP CODE #OF TANKS AT SITE <br /> 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 <br /> ( 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 (8170)x(tanks) ($170)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 CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s <br /> ( ) CLOSURE FEE_$279/TANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279 I FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY $� <br /> REPAIR PLAN CHECK i <br /> TANK ID#(s): <br /> i <br /> ; i <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) <br /> $ Ii <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ect.) <br /> � i <br /> MISCELLANEOUS j <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $93/HOUR $ <br /> i <br /> I <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR $ <br /> SAMPLING INSPECTION FEE _ $93/HOUR $ i <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. (l <br /> OFFICE USE ONLY i <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED - CHECK# RECEIVED BY DATE RECEIVED <br /> SR I <br /> EH 23 032(REVISED 8/01/03) <br />