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,.. .RMAI <br />Remor< <br />TANK ID <br />OUIN COUNTY ENVIRONMENTAL HEALTH <br />UNDERGRL[JND STORAGE TANK PROGRAM FEE WORKSHEET <br />APPLICANT BILLING <br />..rru.wvI c JR IACt NAME - <br />ELITE IV CONTRACTORS, INC. CARRIE MILLER <br />APPLICANT MAILING ADDRESS - APpLJCANT PHONE #WITH AREA CODE <br />2535 WIGWAM DRIVE <br />CITY ( 209) 461 —6337 <br />STATE ZIP CODE CIRCLE WORK TO BE DONE: <br />� CA" 95205 <br />Closure Installation Repair Retrofit " <br />ACTIVE FACILITY <br />_ $s 00 FEE FACIUTYFEE:1 TANK - <br />$125 PER TANK AFTER FIRST TANK <br />...PE <br />1998 <br />tsrrolx(vee) <br />1999. <br />Isno)x(a-nksy <br />2000 <br />2001 <br />2002 <br />2003 <br />- .. <br />$ <br />STOCRTON <br />TANK PENALTY ASSESSED <br />- <br />ACTIVE FACILITY <br />_ $s 00 FEE FACIUTYFEE:1 TANK - <br />$125 PER TANK AFTER FIRST TANK <br />...PE <br />1998 <br />tsrrolx(vee) <br />1999. <br />Isno)x(a-nksy <br />2000 <br />2001 <br />2002 <br />2003 <br />- .. <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />- <br />- $ <br />TANK SURCHARGE = $10 /TANK $ . <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY - $ <br />- INSTALLAI <br />(Plan Cheri; <br />- I TANK ID # (; <br />in Place) <br />=.$279 FTANK # TANKS X $279 = $ <br />LOSURE FEE _ $279:/ FACILITY $ <br />CHECK FEE =.$744 / FACILITY <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 .. - <br />$ , <br />-CONSULTATION FEE _ $ 93/ HOUR _.. <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE =$93/HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR - <br />ALL FEES ARE BASED ON THE S93 HOURLY RATE. TIME THAT EXCEEDS FEESP <br />$ <br />AID WILL BES TO APPUCANT. <br />OFFICE USE ONLY - <br />SERVICEREQUEST a I FACItJ7Y ID AMOUNT RECENED = - CHECK V I DATE RECENED . <br />SR <br />EH 23032 (REVISED 8101/03) <br />