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Apr 04 02 12t19p Elite Iv Contractors Inc 2094616342 p.8 <br />SAN JOAQUIN COUNTY qk <br />ONVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: zvww.sj2ov.or8/ehd <br />FACtWTY NAME <br />FACILITY CONTACT NAME <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />nag -r)n1q <br />FACILITY ADDRESS <br />SIITEE�PHONE <br /># W AREA C E <br />p �aro— <br />r/ <br />CITY <br />TATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA <br />,1 <br />APPLICANT 14ILLING NAME <br />APPLICANT ONTACT NAME <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2005 <br />J � - 940 l <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE CONTRACTOR ICG # <br />J109' <br />Closure Installation Repair Retrofit <br />Al-IIVCI-AUILrI T <br />TANK ID # s) : <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2002-2007) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2008 & New <br />Installs as of 8/1/07) <br />$125 PER TANK AFTER FIRST TANK <br />2002 <br />2003 <br />2004 <br />2005 <br />2006 <br />2007 <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.00t FACILITY <br />$ <br />PERMANENT CLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s) : <br />CLOSURE FEE= $294 /TANK <br /># TANKS X $294 = <br />TEMPORARY CLOSURE <br />Plan Review and inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $294 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # s <br />$ <br />TANK RETROFIT REPAIR FEE = $294 / FACILITY use for monitorin a ui ment, spiN buckets, tank sum s, mise) <br />$" .� <br />PIPING REPAIR FEE = $294 ! FACILITY use for piping, under -dispenser containment, ect <br />$ <br />MISCELLANEOUS <br />APPLICANT. <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 98/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 98 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = S 98/ HOUR <br />ALL FEES ARE BASED ON THE $98 HOURLY RATE_ TIME TRAT I=err=zznc ccre o Am ,., ..._ <br />$ <br />. -- rvu.�. o= mgL"=u iv APPLICAN I. <br />OFFICE USE ONLY <br />SERVICE REQUEST It FACILITY IDAMOUNT RECEIVEb CHECK YF RECEIVED 8Y DATE RECEIVED <br />SR <br />EH 23 032 !REVISED 08/31071 <br />