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SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH APARTMENT <br />UNDERGROUND STORAGE TMK PROGRAM FEE WORKSHEET <br />FACra iY NAME <br />FACILITY CONTACT NAME <br />c�t0eo p4, L-� syr <br />�d <br />FACILITY ADDRESS <br />PHONE !t AREA CODE <br />COY STATE <br />ZI7PCO DE OF TANKS AT SITE <br />CITY <br />CA <br />5-2,10 <br />- - <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) .461-633?. <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE <br />Closure lrlsta&abon Repair Retrofit <br />"SiGC`:CTt'3ri <br />CA'- <br />y.52�i5 <br />IAtS7AiLATION PLAN CHECK <br />4 <br />-I <br />. s. <br />• SANIPUNG �tSPECTiON FEE - <br />• <br />(Ptan Check and Corszstrudion Inspections) . <br />PLAN CHECK FEE _.$7441 FACILITY ". <br />TANK ID (s) : <br />REPLAN CHECK <br />PAIR <br />- <br />TANK LD ;9 (s): $ <br />TANKRETROFTT REPAIR FEE _ $279 / FACILITY (use for matitrinq equiPff"t Wil "bucket. tank sumps, n+ssc.) <br />ACTIVE FACILITY <br />[pIpINGWPARFEE =$279/FACILITY (use for Pipxxundff.drspensercontair„nes►tect) <br />A <br />MISCEU NEOUS . <br />1998, <br />1999- <br />2000 <br />2001 <br />2002 <br />20Q3 <br />UNAUTHORIZED RELEASE EVALUATIOBI FEE : = S 93 / HOUR : <br />_ $ W FEE.INCLUDES IY NCLUDES FACItIFEE + -1 TANK - <br />( $125.PER TANK AFTER FIRST TANK <br />(1170) x cam? <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $101 TANK <br />$ <br />- : <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.5W FACII RY <br />gERIrIAN:ENT CL(SStiKE <br />or Pmnitted Cbsure in Place <br />$ <br />TANK ID 9 (s):. <br />CLOS(F2E FEE =-V79 -TANK # TANKS X $279 = . '- <br />. : •- - - <br />RARY CLOSURE <br />nd in <br />(Plan Review 2spections) <br />$ <br />TANK 101 (s): <br />Y CLOSURE EEE _ $279:/ FACILITY _ <br />IAtS7AiLATION PLAN CHECK <br />4 <br />-I <br />. s. <br />• SANIPUNG �tSPECTiON FEE - <br />• <br />(Ptan Check and Corszstrudion Inspections) . <br />PLAN CHECK FEE _.$7441 FACILITY ". <br />TANK ID (s) : <br />REPLAN CHECK <br />PAIR <br />TANK LD ;9 (s): $ <br />TANKRETROFTT REPAIR FEE _ $279 / FACILITY (use for matitrinq equiPff"t Wil "bucket. tank sumps, n+ssc.) <br />[pIpINGWPARFEE =$279/FACILITY (use for Pipxxundff.drspensercontair„nes►tect) <br />A <br />MISCEU NEOUS . <br />y <br />TRANSFER FEE— $ 20q2t <br />TATION FEE : = S 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATIOBI FEE : = S 93 / HOUR : <br />$ <br />ALL F�$'j�IRE QN THE 593 HOURLY RATE TAJIE THAT EXCEEDS FEES PND YYfIE BE Lill LED"TO APpL3CAKT_ <br />OFFICE USE ONLY { <br />REQUESTS FArlt M m <br />AlilOtAtT RECf3VED. CHECK <br />BY ATE I <br />rSR I <br />