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SAN*OUIN COUNTY ENVIRONMENTAL HEALTHRTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM F�WORKSHEET <br /> . - - FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> e c cCA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ELITE IV CONTRACTORS, INC_ C'_C �d\► �� <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 /> - 199$ ---1999 -2000 . .2001 2002 ' 20n,", <br /> - <br /> $500 FEE INCLUDES FAUUTY FEE+1 TA"IK - (arro)x(Maoks) ($170)x(06-nxs) <br /> $125 PER TANK AFTER FIRST TANK — <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$101 TANK $ <br /> ESTATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> !r rt WANENT H:0St.RC <br /> (Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=-$279/TANK it TANKS X$279= $ <br /> TEA..PORARY CLOSURE <br /> ;Plan Review and Inspe 'zxs1 <br /> T/NK 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 fl(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mist.) <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping.under-ispenser"containment,ect.) $ ': <br /> t <br /> MISCELLANEOUS <br /> i $ <br /> 9 TRANSFER FEE _ $2O <br /> CONSULTATION FEE _ $93/HOUR j <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR $ j <br /> ! <br /> SAMPLING INSPECTION FEE _ $93/HOUR $ I <br /> ALL FEES ARE BASED ON THE 593 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT_ <br /> OFFICE USE ONLY <br /> j" <br /> SERVICE REQUEST 0 FACILITY ID AMOUNT RECEIVED CHECK a -RECEIVED BY, DATE RECEIVED <br /> SR - , <br /> EH 23 032(REVISED W01103) <br />