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ANIL <br />SANJOAQUINPUBLIC HEALTH SERVICES-ENVIRONM <br />UNDERGR ND STORAGE TANK PROGRAM FEE WORKSHEET <br />DIVISION <br />FACILITY NAME FACILITY CONTACT NAME <br />ILITY DRESS <br />PHONE # WITH AREA CODE_ <br />-- <br />i <br />� <br />_ CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />CA <br />-- ___ APPLBCANT BILLING NAME <br />U CONTACT NAME <br />-ELITE IV CONTRACTORS INC. <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE — <br />CITY 209 461-6337 <br />-- STATE ZIP CODE CIRCLE WORK TORE DONE: <br />STOCKTON CA 95205 <br />Closure installation Repair Retrofit <br />ACTIVE FACILITY -- _ <br />$500 i`EE INCLUDES FACILITY FEE + t TANK 1 ryt701996-1999 2000 2001 <br />I xte ass) x (# n <br />125 PER `tANK AFTER FIRST TANK <br />TANY. �ENA4 -_. r tiSSE Sccn t } $ ------ <br />i <br />TANK SURCHARGE _ $8 /TANK �-$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM- $10 / FACILITY $ <br />PERMANENT CLOSURE <br />Removal Or Permitted Closure in place,) <br />TANK ID # (s). CLOSURE FEE= $267 / TANK$'— <br />TEMPORARY CLOSURE # TANKS X S2o7 = <br />(Plan Review and Insgectios) --" <br />ADIK ID 3 (s) : TEMPORARY CLOSURE FEE _ $267 / FACILITY <br />INSTALLATION PLAN CHECK <br />Pian Check and Construction Inspections) <br />TANK 10 # (s) : �PLAN�CHECK�FEE=$712�/FACILITY $ -- — <br />REPAIR PLAN CHECK _ <br />TANK ID # (s) <br />TANK LIMING REPAIR FEE _ $267 / TANK $ fv <br />TANKS X $267 = "0 <br />TANK RETROFIT REPAIR FEE = $267 / FACILITY $ <br />PIPING REPAIR FEE = $267 / FACILITY $ <br />TRANSFER FEE _ $ 20 $ <br />CONSULTATION FEE _ $ 891 HOUR $ <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 89 / HOUR $ <br />SAMPLING INSPECTION FEE _ $ 891 HOUR $ <br />A!1 FEES ARE BASED ON THE 589 HOURLY RATE- TIME THAT EXCEEDS FEES PAD- WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # E FACILITY ID # AMOUNT RECEIVED <br />CHECK # RECFOVFn avDATE RECEIVED <br />SR f 1 I <br />EH 23 x132 (REVISED "-®t1 <br />