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SVAQUIN COUNTY ENVIRONMENTAL HEALTH RTMENT <br />UNDERGUND STORAGE TANK PROGRAM F E WORKSHEET <br />f-AGILI 11'NAME. - - - - FACILITY CONTACT NAME <br />FACILITY ADDRESS SITE PHONE # WITH EA CODE <br />C <br />F <br />J <br />CITY S TE ZIP COD <br />® <br />E # OF TANKS AT SITE <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. CARRIE MILLER - <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />2535.WIGWAM DRIVE <br />CIN STATE Zi(209) 461-6337 <br />P CODE CIRCLE WORK TO BE DONE: <br />STOCKTON CA- 95205 Closure* Installation Repair Retrofit <br />ACTIVE FACILITY <br />FEEINCLUDES FACILITY FEE *.1 TANK <br />$125 PER TAW <br />AFTER FlRSTTANK <br />$ i <br />CONSULTATION FEE _ $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />' ®f I CFFC ADC Re CCfI nM TUC te, u <br />$ <br />® <br />E # OF TANKS AT SITE <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. CARRIE MILLER - <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />2535.WIGWAM DRIVE <br />CIN STATE Zi(209) 461-6337 <br />P CODE CIRCLE WORK TO BE DONE: <br />STOCKTON CA- 95205 Closure* Installation Repair Retrofit <br />ACTIVE FACILITY <br />FEEINCLUDES FACILITY FEE *.1 TANK <br />$125 PER TAW <br />AFTER FlRSTTANK <br />$ i <br />CONSULTATION FEE _ $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />' ®f I CFFC ADC Re CCfI nM TUC te, u <br />$ <br />ACTIVE FACILITY <br />FEEINCLUDES FACILITY FEE *.1 TANK <br />$125 PER TAW <br />1998 1999. 2000 2001 2002 2003 <br />(s»0)X(Ma.k.j (S170tx(resar ) - - .... <br />I <br />$ <br />TANK PENALTY ASSESSED $ <br />TANK SURCHARGE _ $101 TAW$. <br />STATE SURCHARGE FOR FACILITIES RY IN A CUPA PROGRAM =$17.50/ FACILITY $ <br />PERMANENT CLOW - 7 <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSU <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID.# (s): 7_rTEMPO <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) . <br />TANK ID #t (s): <br />REPAIR PLAN CHECK <br />TANK ID it (s): <br />TANK.RETROFIT REPAIR FEE _ $279 / FACILITY (use for monk <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping <br />ts. tank suinps. mist,) <br />int_ -4 . . <br />MISCELLANEOUS <br />AFTER FlRSTTANK <br />$ i <br />CONSULTATION FEE _ $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />' ®f I CFFC ADC Re CCfI nM TUC te, u <br />$ <br />NOT ALREADY ON lNVEWiO <br />PERMANENT CLOW - 7 <br />Removal or Permitted Closure in Place <br />TANK ID # (s): CLOSU <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID.# (s): 7_rTEMPO <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) . <br />TANK ID #t (s): <br />REPAIR PLAN CHECK <br />TANK ID it (s): <br />TANK.RETROFIT REPAIR FEE _ $279 / FACILITY (use for monk <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping <br />ts. tank suinps. mist,) <br />int_ -4 . . <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ i <br />CONSULTATION FEE _ $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />' ®f I CFFC ADC Re CCfI nM TUC te, u <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST # <br />SR <br />EH 23 032 (REVISED 8101 <br />i <br />r <br />- t <br />i <br />tâ–º <br />SURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT- ` <br />ID AMOUNT RECU&D CHECK # RECEIVED BY DATE RECEIVED . <br />