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S�OUIN COUNTY ENVIRONMENTAL HEALTH RTMENT <br />UNDERGMUND STORAGE TANK PROGRAM EE WORKSHEET <br />FACILITY,,NAME <br />FACILITY CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />CARRIE MILLER <br />FACILITY ADDRESS <br />SITE O # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />(209) 461-6337 <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />A� <br />CA <br />95205 <br />u <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />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 />Closure* Installation Repair Retrofit <br />STOCKTON <br />CA <br />95205 <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />CLOSURE FEE =.$279 [TANK <br />1998 <br />1999- <br />2000 <br />2001 <br />2002 <br />2003 <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK - <br />(SnD)x (tuanks) <br />(&»o) x (Manks) <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />( $125 PER TANK AFTER FIRST TANK <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 CLOSUkE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />CLOSURE FEE =.$279 [TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s): <br />TEMPORARY CLOSURE FEE _ $279 / FACILITY . <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction In <br />TANK ID # (s) : <br />is)- <br />PLAN CHECK FEE= $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s): 1 <br />`h <br />TRANSFER FEE _ $ 20 <br />TANK.RETROFIT REPAIR FEE _ $279 / FACILITY (use for monitoring equipment, spill buckets. tank sumps. misc.) <br />j <br />CONSULTATION FEE _ $ 93/ HOUR <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping; under- ispenser containment, ecL) <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR . <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL r— AK= 0^Z CJJ Vn l nc aVJ nwKLT KA 1 r— I ORM l nnl ukt,ctua rcta rAiU "iLL 0r- 0XJ rw 1 V .%rrLr—ms I _ <br />OFFICE USE ONLY <br />SERVICE BEQUEST # FACILITY ID AMOUNT RECEIVED CHECK #r RECErVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 8101103) <br />