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SAN J UIN COUNTY ENVIRONMENTAL HEALTH D ZTMENT UNDERGRO,,.4D STORAGE TANK PROGRAM FLS WORKSHEET FACILITY NAME FACILITY CONTACT NAME CSL `� � � tY1 J C C• c.�• r FACILITY ADDRESS SITE PHONE # WITH EA CODE 2535 WIGWAM DRIVE CG, L, _3 CITY STATE ZIP CODE # OF TANKS AT SITE �_ ca c 2 L TANK PENALTY ASSESSED APPLICANT BILLING NAME APPLICANT CONTACT NAME ELITE IV CONTRACTORS, INC. CARRIE MILLER APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2535 WIGWAM DRIVE $ $ (209) 461-6337 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: S TOCKTON CA 95205 Closure Installation Repair Retrofit ACTIVE $500 FEE INCLUDES FACILITY FEE + 1 TANK $125 PER TANK AFTER FIRST TANK 1998 ($170) x (#tanks) 1999 ($170) x (#tanks) 2000 2001 2002 2003 $ $ TANK PENALTY ASSESSED $ TANK SURCHARGE = $10 / TANK $ STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ 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 4LLATION PLAN CHEC Check and Construction TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY REPAIR PLAN CHECK TANK ID # (s) : $ $ TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) $-271,o PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) $ MISCELLANEOUS TRANSFER FEE _ $ 20 $ $ CONSULTATION FEE _ $ 93/ HOUR T UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR $ SAMPLING INSPECTION FEE _ $ 93/ HOUR AI 1 PFFS ARF RA-z=n nm TUC too $ OFFICE USE ONLY SERVICE REQUEST # FACILITY ID AMOUNTRECEIVED CHECK # RECEIVED BY DATE RECEIVED SR EH 23 032 (REVISED 8101/03)