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SAN JOAOUIN COUNTY ENWONAENTAL W-ALTH DEPARTNfENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FAGU tY X"IE '� <br />FACUW CONTACT NAME . <br />�n <br />tv Y V <br />n <br />FA ADDRESS <br />SITE PHONE 4 WITN AREA CODE <br />2535 -WIGWAM DRIVE <br />(209) AG1=6337 <br />CTTY STATE <br />ZI CODE <br />t (>F TANKS AT SfiE <br />15 <br />' - . - . <br />b <br />APPtJCANT B2LING NAME .. <br />.APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC_ <br />CARRZE HILLER <br />APPLICANT WAILING ADDRESS . <br />APPLICANT PHONE 0 WITH AREA CODE <br />2535 -WIGWAM DRIVE <br />(209) AG1=6337 <br />CITY I STATE <br />j 'Siv tvri { f c A` <br />ZiPmDE. CIRCLE WORKTO BE DONE: <br />i 9�LU� C ! . ,Ciosre 4v4a[amn Rqw Retroa <br />REPAIR PLAN (SCK .. - <br />- <br />TANK LD it L): <br />...:ACTIVE FAC¢ITY- <br />TANKRETRORT REPAIR F1£=52791FACL[TY (sae Lorffmkn Agequipn tspIDbuJ:eis. torics Ps:mac) . <br />.. <br />.. <br />SSW FEE INCLUDES FACILITY FEES I TANK <br />" I S125.PERTAW AFTER FIELSTTA14K <br />.1998 - <br />Cs9%x(uA9 <br />1999. <br />(sno)?P�+1--- <br />2000 <br />-2001.2002 <br />2003 <br />' - . - . <br />b <br />- <br />- -- - TAMC PENALTYASSESS®' <br />TANK SL02CHARGE=$10/TA4j1 <br />- _ <br />$. <br />1 <br />-_ <br />STATE SURCHARGEFOR FACBLIIESNOT ALREADY ON INV3aORY)N A(LPA PROGRAM 4175Gl FAC@3iY <br />or.F'elm"itted(issE eAPiace - <br />-' <br />TAMC ID 0(s)_.- - - <br />CLOME FTE=5279 YTANK <br />LTANKSX$279=_.:- <br />.(Plan FCcviewand 4asyeda(s) <br />. <br />TANK ID.:t (s): - _- <br />_ - - _ <br />TESFbRARY (1(LSURE FEE= $2791 FAC(LTTY - <br />S <br />f - <br />- R:STAL"Tm PLMf.C3fECK <br />(Plan C71ec3 wo Ca mtucTin <br />.. - <br />. - - <br />Pinrl c7Ea( FTE $7441 FACILLTY 7. <br />REPAIR PLAN (SCK .. - <br />- <br />TANK LD it L): <br />TANKRETRORT REPAIR F1£=52791FACL[TY (sae Lorffmkn Agequipn tspIDbuJ:eis. torics Ps:mac) . <br />.. <br />pPING'REPAIRFEE=$279/FACILnY _ (ise Lore Tmde+�spaaeicanrmrac�nt ed7 .. <br />- TRANSFERFFE _$21) <br />Y ONSULTATO)NFEE : = S9NHOlbt <br />$ -A <br />UNAl nXX:ZIZED RELEASE EVALUATION FEE . = S93 1 MR <br />- <br />SAMIN <br />PLG INSPECTM F7£ = S 93/ NOUR <br />- ALLF ES- IZEBASONONIW393HOURLYRATF—T6ETrLATEIMEEDS FEES PAIDMI£BEm LEDTO APPLIL <br />CAN - <br />.. <br />OFFICE USE OWY <br />- DIECKS RECEMMBY OILTEt��- I <br />".SERVKF REOUFSTi FAC[1TYb.. AYOUKTRECFLm '` -� <br />