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SA►*QUIN COUNTY ENVIRONMENTAL HEALTH RTMENT <br /> UNDERGRt7GND STORAGE TANK PROGRAM FFRWORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 9,3q - IS 1 S <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA c1 S 3 V1 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ELITE IV CONTRACTORS, INC. C <br /> �QC" <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 WIGWAM DRIVE ( 209) 461 -6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> STOCKTON CA 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> - I 9998 -19-9 201-JO- 2001 . 20C_�2 r200:'. <br /> ( $500 FEE INCLUDES FAUUTY FEE+1 TANK ks) ($170)X(ztanks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$101 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY 1N A CUPA PROGRAM=$17.50/FACILITY $ <br /> 1 PI keaYAh1EN i �Lv`.":t:itlE � _ <br /> (Removal or Permitted Closure in Place). - <br /> TANK ID#(s): CLOSURE FEE=.$279/TANK #TANKS X$279= $ <br /> TEI?+:?ORARY CLOSURE <br /> E ;Plan Review and inspec;xs <br /> i TA.14K 0#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID Sl(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) $ <br /> PIPING REPAIR FEE _$2791 FACILITY (use for piping,under-dispenser containment,ecL) $ '• <br /> I <br /> MISCELLANEOUS. <br /> ',AN---EqT = S 7_G <br /> II <br /> CONSULTATION FEE _ $931 HOUR j <br /> -- $ T— <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR <br /> I <br /> SAMPLING INSPECTION FEE _ $931 HOUR $ 1 <br /> ALL FEES ARE BASED ON' THE W HOURLYRATL TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST 0 FACILITY ID AMOUNT RECENED CHECK 0 RECEIVED BY DATE RECEIVED <br /> SR ,. <br /> 04 23 032(REVISED 8101103) <br />