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SAN , 2UIN COUNTY ENVIRONMENTAL HEALTH DE ;TMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACrIL(TY NAME FACILITY CONTACT NAME <br />FACILITY ADDRESS SITE PHONE # WITH AREA CODE <br />CITY STATE ZIP CODE <br />#OF TANKS AT SITE <br />CA q a cS <br />ELITE IV CONTRACTORS, INC_ CARRIE MILLER <br />CHECK tY <br />APPLICANT MAILING ADDRESS <br />DATE RECQVED <br />SR <br />APPLICANT PHONE It WITH AREA CODE <br />2535 WIGWAM DRIVE <br />CITY <br />(209) 461-6337 <br />STATE <br />ZIP CODE CIRCLE WORK TO BE DONE <br />STOCKTON CA <br />95205 <br />Closure Installation Repair <br />Retrofit <br />ACTIVE FACILITY <br />- - _ { -. 1 J9[� <br />\+ p p <br />_.$Su^.kr_EL`tikv`tzk:lGa�rrJ�L.[t.i l"i"i"LG '�.-� 1^I -•-K 776Xi=df1�CS <br />I $125 PER TANK AFTER FIRST TAnIK <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $10 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTpRY IN A CUPA PROGRAM =517.50/ FACILITY <br />$ <br />PERMANEN. CLOSURE <br />— — <br />rnoral or Pamitled Casure it Place <br />.. <br />TANK ID 4 (s) : <br />TEMPORARY CLOSURE <br />CLOSURE FEE _ $279 / TANK // TANKS X $279 = <br />$ <br />(Plan Review and Inspections) <br />TANK IDI (s) : <br />TEMPORARY CLOSURE FEE _ $279 / FACIL)TY <br />$ <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID tt PLAN CHECK FEE = $744 / FACILITY $ <br />C)FFlCF IISF nN1 v <br />SERVICE REQUEST >e : FACILITY ID AMOUNT RECENED . - <br />CHECK tY <br />RECEIVED BY <br />DATE RECQVED <br />SR <br />EH 23 032 (REVISED woijo3) <br />