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SAN J UIN COUNTY ENVIRONMENTAL HEALTH D TMENT <br />UNDERGRC D STORAGE TANK PROGRAM F ORKSHEET <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />CARRIE MILLER" <br />APPLICANT MAILING ADDRESS " <br />APPLICANT PRONE # 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 />' Removal or Permitted Closure in Place <br />TANK ID ff (s): <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID .# (s) <br />INSTALLATION PLAN CHECK <br />(Plan Check and (.onstrtrcl_'Ciii it z ctions <br />TANK ID #t (s) : - <br />REPAIR PLAN CHECK <br />TANK ID # (s). <br />TANK RETROFIT REPAIR FEE _ $279 /FACILITY (use for monitoring equipment, spill buckets, tank sumps, mise) $ a <br />-71 <br />PIPING REPAIR FEE _ $279 /FACILITY (use for piping: under -dispenser containment, ect) <br />(�. <br />MISCELLANEOUS <br />TRANSFER _ $ e <br />FEE $ 20 <br />CONSULTATION FEE _ <br />$ 93/ HOUR . <br />UNAUTHORIZED RELEASE EVALUATION FEE _ <br />$93/HOUR <br />$500 FEE INCLUDES FACILITY FEE +1TANK - <br />$125 PER TANK AFTER FIRST TANK <br />1998 <br />($notx(anks) <br />1999 <br />(Sl o)x(#rrts) <br />2000 <br />2001 <br />2002 <br />2003 <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $10 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />$ <br />' Removal or Permitted Closure in Place <br />TANK ID ff (s): <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID .# (s) <br />INSTALLATION PLAN CHECK <br />(Plan Check and (.onstrtrcl_'Ciii it z ctions <br />TANK ID #t (s) : - <br />REPAIR PLAN CHECK <br />TANK ID # (s). <br />TANK RETROFIT REPAIR FEE _ $279 /FACILITY (use for monitoring equipment, spill buckets, tank sumps, mise) $ a <br />-71 <br />PIPING REPAIR FEE _ $279 /FACILITY (use for piping: under -dispenser containment, ect) <br />(�. <br />MISCELLANEOUS <br />TRANSFER _ $ e <br />FEE $ 20 <br />CONSULTATION FEE _ <br />$ 93/ HOUR . <br />UNAUTHORIZED RELEASE EVALUATION FEE _ <br />$93/HOUR <br />$ <br />OFFICEUSEONLY <br />• <br />SERVICE REQUEST X FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE REC <br />SR <br />EH 23 032 (REVISED 8/01/0 <br />- <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />OI 1 CFF' DRG RACFfI Awl TUC tn� ung o. v e •rr v....- �... � .-......-.__ ____ _ _.._ .._.. _ _- _ -_ . -_ _". <br />$ <br />3) <br />CLOSURE FEE =.$279 PTANK # TANKS X $279 = � <br />TEMPORARY CLOSURE FEE _ $279 / FACILITY $ ^ <br />PLAN CHECK FEE _ $744 %FACILITY <br />