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SAN. 2UIN COUNTY ENVIRONMENTAL HEALTH D' RTMENT <br /> UNDERGROuND STORAGE TANK PROGRAM FL- WORKSHEET <br /> rA(T t TY NA E — 0.__._ i..•^A tTY ;ONTACT NAME <br /> FACILITY ADDRESS SITE PHO E#WITH AREA CODE <br /> _ V .4ofCI✓I <br /> YW <br /> CITI( STATE ZIP CODE #OF TANKS AT SITE <br /> ICA <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 <br /> ( 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)xlzra.,ksl (zno)xltttar,ks> -- - <br /> ER FIRST TANK <br /> $125 PERTANK AFT <br /> ' $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> • -- ..=.*1LNT GL:,''°Stink _—� <br /> Removal or Permitted Closure in Place - <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$279/FACILITY <br /> INSTALLATION PLAN CHECK _ <br /> L(Plan Gt.,?ck and Conshu0ion Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ecL) $ <br /> i <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $93/HOUR -- $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR ! <br /> f <br /> SAMPLING INSPECTION FEE _ $93/HOUR i <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE_ TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT- i <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID J-AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8/01103) <br />