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SAN J UIN COUNTY ENVIRONMENTAL HEALTH D TMENT <br />UNDERGROWD STORAGE TANK PROGRAM FORKSHEET <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />GAa)-- fv-ivc- <br />FACILITY ADDRESS <br />CoA/ <br />50MkA S/v (� <br />SITE PHONE # W AREA CODE <br />0 8 ui, C4av-i—ev-U/d <br />(209) 461-6337 <br />20 A)&5-3-1To <br />CITY <br />ZIP CODE <br />STATE <br />21P CODE <br /># OF TANKS AT SITE <br />A/ <br />CA <br />, O L <br />Tx r e4— 3� <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 Re r e fi <br />STOCKTON <br />CA <br />95205 <br />ACTIVE FACILITY <br />TANK ID 4(s): <br />$500 FEE INCLUDES FACILITY FEE + I TANK <br />$125 PER TANK AFTER FIRST TANK <br />1998 <br />(s»ol x (mania> <br />1999 <br />1sr7ol x l#�antsl <br />2000 <br />2001 <br />2002 <br />2003 <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE= $10 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM =$17.50/ FACILITY <br />$J <br />PERMANENT CLOSURE - <br />Removal or Permitted Closure in Place - <br />TANK ID 4(s): <br />CLOSURE FEE _ $279 / TANK # TANKS X $279 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID #(s): <br />TEMPORARY CLOSURE FEE =$2791 FACILITY <br />REPAIR PIAN CHECK <br />CHECK # RECEIVED BY DATE RECENED <br />TANK ID # (s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITYuse for monitodn - <br />(. g equipment, spill buckets, tank sumps, mist.) <br />$ <br />PIPING REPAIR FEE v $279 / FACILITY (use for piping, under dispenser containment, ecL) <br />$ <br />MISCELLANEOUS <br />CHECK # RECEIVED BY DATE RECENED <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 93/ HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE =$93/HOUR - <br />$ <br />SAMPLING INSPECTION FEE _ $ 931 HOUR <br />n.r cccc eoc cnccn nu rut mom --.— —...- <br />$ <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED <br />CHECK # RECEIVED BY DATE RECENED <br />SR <br />