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SM JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM! FEE WORKSHEET <br /> FFAj,ILIIIY NAME. FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHON #WITH AREA CODE <br /> CITY3 <br /> ZIP CODEI OF TANKS AT SITE <br /> CA <br /> ( n <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ELITE IV CONTRACTORS, INC_ CARRIE MILLER- <br /> APPLICANT MAIL NG ADDRESS. APPLICANT PHONE X WITH AREA CODE <br /> 2535 •WIGWAM DRIVE <br /> { 204} 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> STOCKTON CA X5205 Closur6* Installation Repair Retrofit ' <br /> ACTIVE FACILITY <br /> 1998 1999 . 2000 2001 2002 2003- <br /> $500 FEE INCLUDES FACILITY FEE-*•1 TANK . tst7otXp :j (tato�x(s.roll _ <br /> $125 PER YANK AFTER FIRST TANK <br /> TANK PENALTYASSESSED $ <br /> TANK SURCHARGE=$101 TANK $ <br /> STATE SURCHARGE FOR FACILITIES HOT ALREADY ON INVENTORY INA COPA PROGRAM=S17.W FACILITY: $ <br /> ..PERMANENT CLOSUiR>= '- <br /> ovaLa Petmitled-Closure in Placel. _. <br /> TANK 10 9(s): <br /> TEMPORARY CLOSURE CLOSURE FEE=.x279/TANK TANKS X S279= $ <br /> Plan Review and kispections) <br /> TANK I0#(s}: TEMPORARY CLOSURE FEE_$2791 FACILITY' $ <br /> THSTALLATION PLAN CHECK <br /> (Plan Check and ConstrucLon insyedions). <br /> TANK ID#(s). PLAN CHECK FEE_$7441 FACILCFY $ <br /> REPAIR PLAN CHECK - <br /> TANK ID s): <br /> TANK.RETROFIT REPAIR FEE =$279/FACILITY (use for monitoring equipment_spiN buckets,tank sumps,misc.) <br /> PIPING REPAIR FEE _$279/FACILI7Y (use for $ <br /> 2 ander-dispetis4 coistainment ecLI <br /> 'MISCELLANEOUS. I <br /> TRWvSFER FEE _ $2O $ t <br /> CONSULTATION FEE: = S 93/HOUR $ i <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 93 f HOUR . $ <br /> $ s <br /> SAMPLING 9NSPECTTON FEE = S 931 HOUR I <br /> ALL FEES'ARE BASED ON THE$93 HOURLY RATE TIME TftAT EXCEEDS FEES PALO VEtLL t3E BILM70 APPLICANT. I <br /> �. <br /> OFFICE USE ONLY <br /> SERVIM REQUEST it FACILITY D <br /> AMOUNT FtEaWED CNECIS 1 RECE3VED BY DATE RE{EiVEO . <br /> SR <br /> EH 23 032(REVISED E011M I <br /> Z 'd <br /> 2*,E9 T 9ip60Z ou I s.ao,4oe.i,4uo0 AI e4 T 13 dg T s SO S0 6 T osa <br />