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SAN, !UIN COUNTY ENVIRONMENTAL HEALTH D RTMENT UNDERGRG,,AD STORAGE TANK PROGRAM FEC WORKSHEET CAru 1T .1 . Lir - — — FACILITY CONTACT NAME FACILITY ADDRESS SITE PHONE #WITH AREA CODE APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE CITY STATE ZIP CODE # OF TANKS AT SITE 2003 CA ' .�2 L)) ZIP CODE CIRCLE WORK TO BE DONE: APPLICANT BILLING NAME APPLICANT CONTACT NAME ELITE IV CONTRACTORS, INC. CARRIE MILLER APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2535 WIGWAM DRIVE 2002 2003 (209) 461-6337 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: STOCKTON CA 95205 Closure Installation Repair Retrofit ACTIVE FACILITY TANK ID # (s) : CLOSURE FEE = $279 /TANK # TANKS X $279 = $500 FEE INCLUDES FACILITY ,'SEE + 1 TANK $125 PER TANK AFTER FIRST TANK I 1998 ($i70)X (thanks) 1999 ($170) X(thanks) 2000 2001 2002 2003 _ $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $10 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.501 FACILITY $ PERMANENT CLOSURE /Removal or Permitted Closure in Place TANK ID # (s) : CLOSURE FEE = $279 /TANK # TANKS X $279 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 / FACILITY kLLATION PLAN CHECK Check and Construction Ir TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY REPAIR PLAN CHECK AMOUNT RECEIVED CHECK # TANK ID # (s): I $ TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) $� / PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) $ MISCELLANEOUS AMOUNT RECEIVED CHECK # TRANSFER FEE _ $ 20 CONSULTATION FEE _ $ 93/ HOUR I $ $ UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR $ SAMPLING INSPECTION FEE = $ 93/ HOUR All FFFS ARF RAS,Pn nk] TUC cal Lint tot---- ---.... $ OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECEIVED SR FN 72 mg rRFVt,