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SAN OUIN COUNTY ENVIRONMENTAL HEALTH*EWORKSHEET <br />RTMENT <br />UNDERGR ND STORAGE TANK PROGRAM <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 />Installation Repair Retrofit <br />-STOCKTON <br />CA <br />95205Closure' <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK - <br />$125 PER TANK AFTER FIRST TANK <br />1998 <br />($no) X (manks D <br />1999. <br />(snotxtmanks> <br />2000 <br />2001 <br />2002 <br />2003 <br />- <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $10 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />$ <br />Removal or Pertnitted.Closure in Place <br />TANK ID # (s) <br />TEMPORARY CLOSURE <br />(Plan Review and inspections) <br />TANK ID # (s) <br />RNSTALLAiION PLAN CHECK <br />.Plan Check and Constr cbor-s Inspectie�,ns) <br />r TANK !D # (s) <br />)SURE FEE =-$279 /TANK # TANKS X $279 = $ <br />ePORARY CLOSURE FEE _ $279 / FACILITY $ <br />s <br />PLAN CHECK FEE =.$744 %FACILITY <br />! $. <br />REPAIR PUUV CHECK <br />TANK ID # s) <br />TANK RETROFIT REPAIR FEE _ $279 /FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) $ <br />PIPING REPAIR FEE =$279/FACILITY (use for piping; under -dispenser containment, ecL) <br />MISCELLANEOUS <br />TRANSFER _ $ <br />FEE $ 20 ? <br />CONSULTATION FEE _ $ <br />$ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ - $ <br />$ 931 HOUR <br />SAMPLI <br />� $ <br />OFFICE USE <br />NG INSPECTION FEE _ $ 93/ HOUR <br />All CCCC'AOC QACCn AN TctC ln�u�c-..vn•tr ....��...�. ...._�-_-�-_____.___. _-_-.-�. - .. <br />$ <br />ONLY <br />SERVICE REQUEST # <br />SR <br />AGILITY ID AMOUNT RECEIVED CHECK a <br />EH 23 032 (REVISED E/01 <br />RFCFivcn cxv nerc ocrcnicn <br />