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SAN JftUIN COUNTY ENVIRONMENTAL HEALTH D TMENT <br />UNDERGR u D STORAGE TANK PROGRAM FEE WORKSHEET <br />�--- <br />$ <br />UNALMIORVED RELEASE EVALUATION FEE _ $ 93 / HOUR -' <br />NAME <br />FACILITY CONTACT NAME <br />fFACII-FACILITY <br />ADDRESS <br />SITE PHONE # WITH AREA CODE <br />CITY <br />STATE <br />ZIP CODE > <br />rP! <br /># OF TANKS AT SITE <br />CA <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC_ CARRIE MILLER <br />APPLICANT MAILING ADDRESS 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 />S TOCKTON <br />CA <br />95205 <br />Closure Installation Repair <br />Retrofit <br />ACTIVE FACILITY <br />Li € _.0 e ($179) X (&tanks) <br />PER "t <br />(WO) X (&tanks) <br />- <br />$125 TANK AFTER FIRST ANK <br />TAN{< PENALTY ASSESSED <br />$ <br />TANK SURCHARGE _ $10 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA COPA PROGRAM <br />$ <br />=$17.5G1 FACILITY <br />PE ` CLOSURE <br />.. R-emoval or Pen ' led Ciosure it Pure .. ... - _ - . - ... <br />.. <br />TANK ID # (s) : <br />TEMPORARY CLOSURE <br />CLOSURE FEE _ $279 / TANK <br /># TANKS X $279 = <br />$ <br />(Plan Review and Inspertions) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $279 f FACILITY <br />$ <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s): <br />PLAN CHECK FEE _ $744 / FACILITY <br />$ - <br />AIR CHECK <br />r <br />K ID # (s) <br />TANK.RETROFIT REPAIR FEE _ $279 / FACILITY (use for monitodn — <br />g equipment, spit! buckets, tank sumps, mise) <br />$ ° <br />j <br />PIPING REPAIR FEE _ $279 /FACILITY (use for piping, under-lisperiser containment ect) <br />$ <br />MISCELLANEOUS <br />_ <br />TRANSFER FFE _ $ 20 <br />CONSULTATION FEE _ $ 931 HOUR - <br />�--- <br />$ <br />UNALMIORVED RELEASE EVALUATION FEE _ $ 93 / HOUR -' <br />$ <br />SAMPLING INSPECTION FEE _ $ 931 HOUR a <br />,,.ALL FEES ARE BASED ON THE S93 HOURLY RATE TtFAF T:6eT �vrccnc crcr es:`... � . , <br />OFFICE USE ONLY <br />