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Y Y <br /> SA QUIN COUNTY ENVIRONMENTAL HEALTHPARTMENT <br /> UNDERGR ND STORAGE TANK PROGRAMWORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME —� <br /> FACILITY ADDRESS Y SITE PHONE"OWITR AREA CODE <br /> CITY STATE Zt CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ELITE IV CONTRACTORS, INC_ JCC. n i-(L- Lj(!-b <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 WIGWAM DRIVE <br /> ( 209) 4.61 -6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> STOCKTON CA _F9 5205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 12003 <br /> �=EE:N;:,,ijIDES FAi-iu iY i=i lL+1 TANK - 41,7�f X(#tanks) (SSTo)x(Nlanksl <br /> $125 PER TANK AFTER FIRST TANS , <br /> I � <br /> T%tNKPENAL'aY ASSESSED � t <br /> TANK SL rtCHARGE='A0 i TANK 1 <br /> STATE SUR{HPR 1 `, - <br /> GE FOR FACILITIES NOT ALREAI!e 71 i livvcrGi':'Y IN A I�JPAr kc; �f1ty1=$17.50 FA IUB iY <br /> iiv.amoval or Permitted Closure in Place) - r <br /> TANK ID#(s): - CLJSURE£Eli_S279/TAN. #TANKS Y.$275 <br /> ' h•`'OF AR Y CLOSURE _ -____ <br /> I PI:n R+,vir-and lnspe,�;x;s <br /> TEMPORARY CLO:af2E FEE_$ 79/FACILITY <br /> If4STALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID;#(s): PLAN CHECK FEE_$7441 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) — —- — <br /> TANK RETROFIT REPAIR FEE =$2791 FAC 11_iTY {usa for moaetoring equipment,spill buckets,tank sun.p misc.) <br /> PIPING REPAIR cEE _$279/FACILITY I - <br /> -_- - {use for piping,under�ispenser containment,ecL} ! <br /> MISCELLANEOUS , <br /> r <br /> CONSULTATION FEF = $�;31HOUk <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $9:,i HOUR $ j <br /> $ r <br /> SAMPLING INSPECTION FEE _ $93/HOUR _ <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAI EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST#j FACILITY ID AMOU;.T RECEIVED CHECK 0 RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8101!03) <br />