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( ' AOUIN COUNTY ENVIRONMENTAL HEALTH DOITMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILI rY NAME. FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE OWITH AREA CODE <br /> CRY STATE 23?CODE S OF TANKS AT SITE <br /> n� 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(DDE- CIRCLE WORK TO BE DONE <br /> -S TOCKTON CA ( 9.52(}5 Closure Irstalation Repair Retrofit <br /> ACTIVE FACILITY <br /> + 7998 1999" 2000 2001 - 2042 2M3- <br /> _ $50QFEEINCLUDESFACILITY FEEI TAW - (sr7o)x( �t <br /> ? p7o).x(msl <br /> I -._ — - - - - <br /> $125.PERTAWAFTERFIRST-TANK <br /> $ <br /> ` TANK PENAL.TYASSESSED - $ <br /> TANK SURCHARGE_$'lo/TANK $ <br /> : STATE Su2CHARGE FOR FAGItTIES NOT ALREADY ON IN WORY.IN A CUPA PROGRAM=$17.5GI FACILITY <br /> -� PE T CLOSURE <br /> or-Pemitted Closure in <br /> TANK ID S(s) CLOSIRE FEE=.$279(TANK #TANKS X$279= <br /> TENIPORARY CLOSURE <br /> (Plan Review and kmpec&=) <br /> - $ I <br /> TANK ID.#(s) TBPORARiCLOSURE FEE=$279:/FACILITY . <br /> f <br /> INSTALLATION PLAN.CHECK <br /> (Plat.Check and Inspections) -. <br /> TANK ID 4(s): PLAN CHECK FEE._.$744!FACILfIY <br /> REPAIR PLAN CHECK <br /> TANK ID ft s) <br /> TANK_RETRORT REPAIR FEE _$279/FACILITY (use for mmbring equipment,spiill-buckets,lank scrinps.rnisc) 79. <br /> PIPINGREPAIR FEE =$279/FACILITY (use forpryMunderdcspeiiserixidaeunent ect) $ <br /> • MISCELLANEol3S - : ..l <br /> TRANSFER FEE ` $ <br /> CONSULTA'nON FEE : _ $931 HOUR _ L <br /> UNAUTHORIZED RELEASE EVALUATION FEE .= S 9tIt3/HO $ _ g <br /> SAMPLING N FEE = S 93/HOUR _. <br /> ' ALL FEES-ARE BASED ON THE$93 HOURLY RATE-TIME THAT EXCEEDS FEES PAID WILL BE 'TO APPLJCANT- <br /> OFFICE USE ONLY s <br /> s FACILITY93 AMOUNT REC>3VED-= CHECK t ' BY allTE ° <br /> SR <br />