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' SAN.10AOUIN COUNTY ENVIRONMENTAL HEALTH DEFT TMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACra i Y NAME, FACILITY CONTACT TAME <br /> FACILITY ADDRESS SITE PHONE 4 WITH A CODE <br /> _- <br /> CITY" STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME: <br /> ELITE IV CONTRACTORS, INC_ CARRIE MILLER <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 .WIGWAM DRIVE <br /> ( 209) .461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> STOCKTON CA"- 95205 Closure InstAaSon epa Retrofit " <br /> ACTWE FACtLTTY <br /> 1998 - 1999- 2000 2001 - 2002 2003 <br /> - $50O EEE INCLUDES FACILITY FEE:@,1 TANK - <br /> $125.PER TALC AFTER FIRST TANK <br /> TANK PENALTY ASSESSED - <br /> TANK SURCHARGE=$101 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=517.W FACILITY <br /> - i <br /> PEFMANENT CLOSURE <br /> TANK ID#(s):, CLOSURE FEE=-$279(TANK tl TANKS X$274= - <br /> TEMPORARY CLOSURE <br /> (Plan Review and kispec6ons) <br /> >. . TANK ID.#(s): TEMPORARY CLOSURE FEE_$279J FACILITY . <br /> INSTALLATION PLAN CHECK <br /> (Ptah Cxteck and Coastructico Inspections) <br /> TANK ID#(s): M1 -- PLAN CHECK-FEE=.$744 I FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID;9 s) <br /> TANK.RETRORT REPAIR FEE _$2791 FACILITY (use for morator equipment.--pr7t buckets,tank sumps.misc.) <br /> PIPWGV REPAIR FEE =$279/FACILITY (use for pF twt-iderdspeiisei containment ectl 7 <br /> MISCEL LANEOUS t <br /> TRANSFER FEE _ $20 <br /> CONSULTATION FEE : = S 93/HOUR _ <br /> UNAUTHORIZED RELEASE EVALUATION FEE . _ $93/HOUR <br /> SAMPLING INSPECTION FEE = S SW HOUR <br /> ' ALL FE1rS ARE SASM ON THE$93 HOURLY RATE THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT- 1 <br /> OFFICE USE ONLY <br /> SERVICE FMQUESTt FACAM V RECEIVED BY 047ERECEMMI <br /> SR <br />