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ROAQUIN COUNTY EN1/tRat3IJENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FAC f elf NAKE. FACILITY CONTACT NAME <br /> 5 rete ,' <br /> FAC:Lm ADDRESS SITE PHONE 9 WITH AREA CODE <br /> 161-7 (zloc, <br /> CRY- STATE ZIP CODE IS OF TANKS AT SITE <br /> L CA 5 0 <br /> APPLICANIT Bft- NG NAMiE APPLICANT CONTACT NAME <br /> ELITE IV CONTRACTORS, INC_ CARRIE MILLER <br /> APPLSCANT MAILING ADDRESS- APPLICANT PHONE WITH AREA CODE <br /> 2535 .WIGWAM DRIVE ( 209) -461-6337 " <br /> CITYSTATE ZW ODDE CIRCLE WORK TO BE DONE <br /> S TvCRTviv j (A ( y�2U5 Closure* Irmtalabon Repan Retroa <br /> ACTIVE FACILITY <br /> 1998 - 2999- 2000 2001 - 2002 2003- <br /> W FEE.INCLUDES FACILITY F1 E+1 TANK - (Snolx(maj IsnolxtI - - - - - <br /> S225.PER TANK AFTER FIRST-TANK <br /> TANK PENALTYASSESSED _ <br /> TANK SURCHARGE_$101 TANK $. <br /> STATE SMCHARGE FOR FA" SNOT ALREADY ON ORY.iN A CUPA PR $17.5GY FACILITY: <br /> PERLdANIENT CLO$IIRE " <br /> orPeffnitted Closure Place - <br /> TANK ID (s): CLOSURE FEE=5279 r TANK 1t TANK X$274= $ <br /> TEMPORARY CLOSURE <br /> (Pian RL-view and kmpecGats) j <br /> TANK ID-0(s)= TELMRARY CLOSURE FEE_$2791 FACIL(7Y <br /> MSTAL. ATICMFPLAN.CHECK <br /> (Plan Check and Conch clam Inspections) <br /> TANK ID;#(s): PLAN!CHECK FEE $744 I FAC9Lf TY <br /> REPAIR PLAN CHECK <br /> TANK 11317(s): <br /> TANKRETROFTT REPAIR FEE _$279/FACILITY (use for manbcing equipment spffl buckets,tank suinps.risk-) 7 <br /> PIPINGREPAiR FES _$279/FACILITY (use forpiphxunder-&spensec cohtak=ienlL ect) <br /> UtSCELLAUEOtIS <br /> _TRANSFER FEE _ $21 <br /> -CONSULT-ATION F : _$93r HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE . _ $931 HOUR <br /> SAA(PLING INSPECTION FEE = S 931 HOUR i. <br /> ALL FEES"T1FZE BASED ON TW$93 HOURLY RATE_TW-THAT EXCRDS FEES PAID WLE BE M-ED-TO APKICAN7_ I <br /> OFFICE USE ONLY = I: <br /> =. REQUESTS FACILITY 13 RECEIVED--` CFiEGC S ` RECE3IIED t3Y ATERECENEDI <br />