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SAIMAQUIN COUNTY ENVIRONMENTAL HEALTH I&RTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACII I NAME FACILITY CONTACT NAME " <br /> FACILITY ADDRESS SITE PHONE#WITH AR CODE <br /> 9 - <br /> CITY. ATE ZIP CODE - #OF TANKS AT SITE <br /> CA - <br /> APPLICANT BILLING NAME - APPIlCANTCONTACTNAME <br /> ELITE IV CONTRACTORS, INC_ CARRZE MILLER. <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 WIGWAM DRIVE ( 209) 461-6337 <br /> CITY STATEI ZIP CODE- CIRCLE WORK TO BE DONE: <br /> -STOCRTON CA -95205 Closure Installation Repa"u Retrofit <br /> ACTIVE FACILITY - - <br /> 1998 1999 . 2000 2001 2002. 2003 <br /> _ $500 FEE INCLUDES FACILTfY FEE+I TANK . 490)X� xm)? tst>o) ( _ -- . . <br /> $125.PER TANK AFTER FIRST TANK - $ <br /> $ <br /> TANK PENALTYASSESSED - <br /> TANK SURCHARGE=$10/TANK " <br /> " STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.W FACILITY <br /> ... ._.... '('PERMANENT CLOSURE <br /> Removal m Pem0ed Cbsum in - <br /> $ <br /> TANK ID#(s)- CLOSURE FEE=.$279/'TANK 9TANKS X$279= <br /> TEMPORARY CLOSURE <br /> (Plan Review and kmpecfions) <br /> TANK ID.#(s): TEMPORARY CLOSURE FEE $279/FACILITY <br /> INSTALLATION-PLAN CHECK - . . <br /> (Plan Check and Construction Inspections) - . ... -. . <br /> TANK ID$1(s)- - — "PLAN CHECK FEE_$744 I FACILITY - I <br /> REPAIR PLAN CHECK - . - - <br /> i <br /> TANK ID#Ls): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for mmitain9 equipment,splA buckets,tank suinps.Misr.) <br /> $ <br /> PIPING REPAIR FEE _$279/FACILITY fuse for piping'tinder- ispemer coMaiwwot ecL) <br /> MISCELLANEOUS - <br /> . . $. t _ - <br /> - - TRANSFER FEE _ $20 <br /> " .CONSULTATION FEE : _ $931 HOAR <br /> UN/AUTHORIZE13 RELEASE EVALUATION FEE _ $931 HOUR - <br /> $ i <br /> SAPAPU14G INSPECTION FEE = S 931 HOUR <br /> . AL1 FEES"ARE BASED ON THE$93 HOURLY RATE TWE THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACWnm AMOUNTRECFNED ..I CHEM# - RECEIVED BY DATE RECEIVED - <br /> SR <br /> Ell 230= a-n WM3) <br />