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SAN J UIN COUNTY ENVIRONMENTAL HEALTH D TMENT <br />UNDERGRO D STORAGE TANK PROGRAM FE WORKSHEET <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />(209) 461-6337 <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />CITY <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />livo <br />CA <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) 461-6337 <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />S TOCKTON CA <br />95205 <br />Closure Installation Repair Retrofit <br />i 1995 1 1999 2000 120012002 200 I� <br />500 FEE :LUDO S FACILITY FEE -F !TANK 170"; <br />I T125 PER TANK AFTER FIRST TANK -- - -- --- _. <br />TANK PENALI Y ASSESSED <br />.N SURCHARGE � X10 / TAFIK $ <br />ST,!-, a S �R(;HAI�G f UR FACILITIES NOT Ar..; -At)Y ON INVENTURY IN A C:UPA PROD M =,,SS1i e a p ,1 <br />PERMANENT CLOSURE <br />RernOvaf cr t-er, witted Closure in Place <br />KIK ID # (3) n — — CLOSURE E ; 9 / TANK TAN 3 X :N2711 <br />- $ <br />�t K 0. Y CLOaURI -- —_ _ _ . <br />evieW and Inspections) <br />TANK ID # (s) : TEMPORARY CLOSURE FEE _ $279 / FACILI fY $ <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />REPAIR PLAN CHECK <br />T1.1,1K RETROFIT REPAIR FEE = $279 / FACILITY_ (use for <br />PIPiNG REPAIR FEE = $279 / FACILITY (use for <br />PLAN CHECK FEE = $744 / <br />tank sumps, mise <br />CONSULTATION FEE - $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR $ <br />SAMPLING INSPECTION FEE _ $ 931 HOUR _ $ <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID W LL BE BILLED TO APPLICANT. <br />° FFECE USE ONLY <br />rSFRI�lCE4tEQUEST # FACILITYID �OUNT R `b;;EIVED GF;7CK # RECEIVED BY DATER f °m <br />EH 23 032 (REVISED 8!01/03) <br />