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SAN "UIN COUNTY ENVIRONMENTAL HEALTH qWRTMENT <br />UNDERGRCWND STORAGE TANK PROGRAM WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />CARRIE MILLER <br />FACILITY ADDRESS <br />S PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />(209) 461-6337 <br />CITY <br />I STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />STOCKTON <br />CA <br />95205 <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 # (s) : <br />$500 FEE INCLUDES FACILITY FEE + 1- TANK <br />I $125 PER TANK AFTER FIRST TANK <br />1998 <br />($170) x (Ranks) <br />1999 <br />($170) x manks) <br />2000 <br />2001 <br />2002 <br />2003 <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $10 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place - <br />TANK ID # (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 <br />(Plan Check and <br />TANK ID # (s) <br />PLAN CHECK FEE = $744 / <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />$ <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, mist.) <br />$ 0 L <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) <br />$ <br />MISCELLANEOUS. <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 93/ HOUR _ <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL FEES %ARE BASED ON THE <br />$ <br />$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # UFACILITY ID AMOUNT RECEIVEDCHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 8/01/03) <br />