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SAN JJMUIN COUNTY ENVIRONMENTAL HEALTH D RTMENT UNDERGR STORAGE TANK PROGRAM F�ORKSHEET FACILITY NAME FACILITY CONTACT NAME ELITE IV CONTRACTORS, INC. CARRIE MILLER FACILITY ADDRESS SITE PHONE # WITH ARE E 2535 WIGWAM DRIVE (209) 461-6337 CITY STATE ZIP CO E # OF TANKS AT SITE Lac �1 ` C� t CA 95205 APPLICANT BILLING NAME APPLICANT CONTACT NAME ELITE IV CONTRACTORS, INC. CARRIE MILLER APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2535 WIGWAM DRIVE (209) 461-6337 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit STOCKTON CA 95205 ACTIVE FACILITY Removal or Permitted Closure in Place -CLOSURE $500 FEE INCLUDES FACILITY FEE + 1 TANK $125 PER TANK AFTER FIRST TANK 1998 ($170) x (#tanks) 1999 ($170)x (#tanks) 2000 2001 2002 2003 Al CCC¢ AMC MACCn — —ten.. u—u— --.–l...--._��..__--'_---_--.---_ TANK PENALTY ASSESSED $ TANK SURCHARGE = $10 /TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM =$17.50/ FACiLIT`' � $ PERMANENT CLOSURE Removal or Permitted Closure in Place -CLOSURE TANK ID # (s) : FEE= $279 /TANK_ # TANKS X $279 = TEMPORARY CLOSURE �- (Plan Review and Inspections) TANK ID # (s) _ t`TEMF�0RARY CLOSURE FEE = $279 I FACILITY _ 1 INSTALLATION PLAN CHECK -- (Plan Check and Construction Inspections) TANK ID # (s) PLAN CHECK FEE _ $744 !FACILITY REPAIR PLAN CHECK TANK ID # (s): $ TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) $ PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect) $ MISCELLANEOUS TRANSFER FEE _ $ 20 $ CONSULTATION FEE _ $ 93/ HOUF__ $ UNAUTHORIZED RELEASE EVALUATION FEF_ = $ 93 i HOUR $ SAMPLING INSPECTION FEE _ $ 93/ HOUR Al CCC¢ AMC MACCn — —ten.. u—u— --.–l...--._��..__--'_---_--.---_ — I --- � -- a %J �-r "k-pkm 1. OFFICE USE ONLY SERVICE REQUEST # FACILITY ID N AMOUNT RECEIVED _ CHECK # RECEIVED BY DATE RECEIVED -- --�— SR EH 23 032 (REVISED 8/01/03)