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SAN NPUIN COUNTY ENVIRONMENTAL HEALTH t�RTMENT <br /> UNDERGRG�JND STORAGE TANK PROGRAM *WORKSHEET <br /> FACILITY NAME - FACILITY CONTACT NAME <br /> 1 <br /> FACILI ADD ESS SITE PHONE#WITH AREA CODE <br /> S 5o D 9 -.2 2 6 �- <br /> CITY I STATE ZIP CODE I #OF TANKS AT SITE <br /> CA 9,S.2 OS <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ELITE IV CONTRACTORS, INC. CARRIE MILLER <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 WIGWAM DRIVE ( 209 ) 461 -6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> STOCKTON CA 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK - ($no)x(gwks) ($170)x(AWk, - - - - <br /> $125 PER TANK AFTER FIRST TANK <br /> i <br /> I TANK PENALTY ASSESSED __�_ $ <br /> TANK SUR!::-TARGE=$10/TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$17.50/FACILITY <br /> i PERMANENT CLOSUR: . <br /> Removal orPerrnided Closure in Place) _ _ _ _� <br /> TANK iD#(s): V _ CLOSURE FEF__$279/'TANK #TANKS X$279 <br /> TEMPORARY CLOSURE <br /> I 'Paan Review and Inspec0o,ts) <br /> TA,41' 044'/ TEMPJRARY CLOSURE FEE_$279/FACILITY <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and ConstruMion Inspections) <br /> TANK ID#(s): �- PLAN CHECK FEE_$744/FACILITY $ <br /> REPAIR PLAN CHECK <br /> I <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$279/FACILITY use for monitoring equipment,spill buckets,tank sumps,mist.)$� <br /> PIPING REPAIR FEE =$279/FACILITY (use for piping,underdis eriser containment,ect <br /> MISCELLANEOUS <br /> I <br /> TRANSFER FEE _ $20 _ $ _ <br /> CONSULTATION FEE _ $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR $ <br /> I <br /> SAMPLING INSPECTION FEE = $93/HOUR $ <br /> ' ALL FEES ARE BASED ON THE$83 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED - CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8101103) <br />