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S QUIN COUNTY ENVIRONMENTAL HEALTH RTMENT <br />UNDERG UND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME. <br />FACILITY CONTACT NAME <br />- — <br />141/1 j, 111 5.(% <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />43 7,S J l l u c/ <br />7 S S 3.s <br />CITY I STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA <br />9,53 7 Jo <br />STOCKTON <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />CARRIE MILLER <br />APPUCANT 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 />1998 <br />1999. <br />2000 <br />2001 <br />2002 <br />21303 <br />$vO0 FEE.INCLUDES FACILITY FEE i TANK - <br />($no)x(Manks) <br />Islrolx(abroks). <br />�. $125 PER TANK AFTER FIRST TANK <br />' TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE _ $10 / TANK <br />$. <br />STATE SURCHARGE FOR ACILCTIES NOT -ALREADY O F N INVENTORY IN A CUPA PROGRAM =$17.501 FACILITY <br />$ <br />-_ _ . ..�E ANENT CLOStiitE - <br />Removal or Permitted Closure in Place . <br />TANK 1D ;t (s): <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID .# (s) <br />- <br />INSTALLATION PLAN CHECK <br />(Plan Check and Constriction Inspections) <br />_ l TANK ID #t (s) <br />)SURE FEE =-$279 /TANK # TANKS X $279 = $ <br />IPORARY CLOSURE FEE _ $279 / FACILITY - $ <br />PLAN CHECK FEE _ $744 % FACILITY • <br />i <br />Dnitoring equipment, s(xlt buckets, tank sumps, mist.) <br />Nng; undertfispenser containment ecL) $ <br />i <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 /HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR $ <br />' 6f t GFLC' ADC VACC(. AAI Tut e.. <br />USE ONLY <br />t <br />i <br />c <br />rEDS) EES PAID WILL BE B <br />1 <br />OFFICE <br />USE ONLY <br />t <br />i <br />c <br />rEDS) EES PAID WILL BE B <br />1 <br />OFFICE <br />