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SAN"UIN COUNTY ENVIRONMENTAL HEALTH RTMENT <br /> UNDERGROWD STORAGE TANK PROGRAM FWF WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> I <br /> FActurAD RESS SITE PHONE#WITH AREA CODE <br /> Ukt 1Qc- <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> r ' <br /> m 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 ( 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 /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x(#tanks) ($170)x(wanks) <br /> $125 PER TANK AFTER FIRST TANK <br /> s <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(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#(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mise) $ 9 <br /> $ <br /> PIPING REPAIR FEE =$279/FACILITY (use for piping,under-dispenser containment,ect) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $93/HOUR <br /> $ I UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR i <br /> SAMPLING INSPECTION FEE _ $93/HOUR $ i <br /> ii <br /> ALL FEESAREBASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> { <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY I DATE RECEIVED <br /> EHIR23 032(REVISED 8101/03) <br />