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• SA )AOUIN COUNTY ENVIRONMENTAL HEALTH E �RTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILI IY.1AME{� FACILrIX CONTACT NAME <br /> FACILfTY ADDRESS SITE PHONE WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> i CA <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 /> S TOCKTON CA - 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 - 20002001 2002 2003 <br /> $-00 FEE INCLUDES FACILITY FEE+1 TANK <br /> ( $125 PER TANK AFTER FIRST TANK $ <br /> _TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$101 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY <br /> .i-PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=.$279 PTANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279:/FACILrTy . <br /> INSTALLATION PLAN CHECK <br /> (Pian Check and Cortst action LRspections) <br /> TANK ID#(s): PLAN CHECK FEE=$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK.RETROFIT REPAIR FEE _$279/FACILJTY (use for monitoring equipment,spflt buckets.tank sumps.misc_) <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping.under- ispensercontainment ecL) <br /> i <br /> i <br /> MISCELLANEOUS. <br /> $ <br /> TRANSFER FEE _ $20 <br /> "CONSULTATION FEE _ $93/HOUR $ — <br /> i <br /> UNAUTHORIZED RELEASE EVALUATION FEE . _ $931 HOUR <br /> $ s <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT_ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST t FACILITY ID AMOUNT RECENED CHECK 0 RECEIVED BY DATE RECENED <br /> SR �. <br /> EH 23 032(REVISED W01103) <br />