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SAN JO IN COUNTY ENVIRQNMENTAL HEALTH D5MRTMENT <br />UNDERGROWD STORAGE'TANK PROGRAM FIWWORKSHEET <br />APPLICANT BILLING NAME <br />FACIL CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE #WITH AREA CODE <br />J SITE PHONE #WITH AXEAVbDE <br />IJrfz <br />MY 01 <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />STOCKTON <br />CA <br />95205 <br /># (s) :F <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 />1998 1999 2000 2001 2002 2003 <br />$500 FEE INCLUDES FACILITY FEE + I TANK ($170) X (#tanks) ($170) X (Manks) <br />"125 PER TANK AFTER FIRST TANK <br />$ <br />T.1kNK PENALTYASSESSED $ <br />-A.NK SURCHARGE = $10 / TANK $ <br />E SUKGHARGE FOR FACILITIES NOT ALREADY ON IN N' e,,Ri' IN A CUPA PROGRAM =$17.50/ FACILITY $ <br />PERM ANENT CLOSURE <br />(Removal or Permitted Closure in Place) <br />$ <br />TANK ID 4 (s): <br />CLOSURE FEE = $279 / TANK <br /># TANKS X $279 = <br />TEMPORARYCLOSURE <br />N ''.* n Review and Inspections) <br /># (s) :F <br />TEMPOFV,,RY CLOSURE; EE -- $2791 FACILITY <br />W.—ALLAnON PLAN CHECK <br />(Plan Check and Construction inspections) <br />TANK ID # (s): <br />FLAN CHECK FEE =$744 /FACILITY <br />r-AEPAIR PLAN CHECK <br />TANK iD # (s). <br />$ <br />TANK RETROFIT REPAIR FEE $279 1 FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) J/ btv <br />PIPING REPAIR FEE = $2791 FACILITY (use for piping, under-d;spenser containment, Pct.) <br />TRANSFER FEE $20 <br />CONSULTATION FEE $ 93/ HOUR <br />UNAUTHORIZED RELEASE E\, ALUATION FEE = $ 93 <br />SAMPLING INSPECTION FEE $ 931 HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOU <br />SR <br />EH 23 032 (REVISED 8/01/03) <br />RECEIVED <br />$ <br />