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SAWNhAQUIN COUNTY ENVIRONMENTAL HEALTH rAh&RTMENT <br />UNDERGFWJND STORAGE TANK PROGRAM FTEEWORKSHEET <br />FACILITY NAME -_ - <br />FACILITY CONTACT NAME <br />ELITE IV CONTRACTORS, INC_ <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />FACILITY ADDRESS <br />SITE PHONE 9WITH AREA CODE <br />AM' I 1 <br />CITY <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA <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 <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 />TANK ID # (s) : <br />CLOSURE FEE =-$279 /'TANK <br />1998 <br />1999- <br />2000 <br />2001 <br />2002 <br />2003 <br />$500 FEE INCLUDES FACILITY FEE +.1 TANK - <br />($17D)X(raank�} <br />ts170lx(man ) <br />SAMPLING INSPECTION FEE _ $ 931 HOUR <br />�. $125 PER TANK AFTER FIRST TANK <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE _ $101 TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.501 FACILITY <br />PERMANENT CLOSUkE <br />Removal or Permitted Closure in Place)_. . <br />TANK ID # (s) : <br />CLOSURE FEE =-$279 /'TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $279 / FACILITY <br />INSTALLATION PLAN Cl <br />yy (Pian Check and Construc <br />1 TANK ID;V (s) : <br />N CHECK FEE = $74t / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # s) <br />$ <br />TANK.RETROFff REPAIR FEE _ $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, mise) <br />�.. <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping. under -dispenser containment, ecL) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 931 HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 931 HOUR <br />.—.�.---��.e.� .... ... e...,......v.. .c.. su.�L.nna rnna.cra�JCGCJ Piu6J Yl ILL. OG BSu ��.•IV ACYLf(.Nt�il_ <br />OFFICE USE ONLY <br />SERVICE REQUEST S FACILITY ID AMOUNT RECWM CHECK At RECEIVED BY <br />SR <br />EH 23 032 (REVISED 3101103) <br />