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SA AOUIN COUNTY ENVIRONMENTAL HEALTH L �RTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />� <br />FACILITY CONTACT NAME <br />APPLICANT MAILING ADDRESS <br />_ <br />2535 WIGWAM DRIVE <br />(209) 461-6337 <br />FACILITY ADDRESS <br />ZIP CODE <br />SITE PHONE it WITH ):A O E- <br />STOCKTON <br />95205 <br />GfTY <br />$125 PER TANK AFTER FIRST TANK <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC_ <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />(209) 461-6337 <br />CITYECA <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />STOCKTON <br />95205 <br />ACTIVE FACILITY <br />TANK ID # (s) : CLOSURE FEE =.$279 /TANK <br /># TANKS X $279 = <br />1998 <br />1999. <br />2000 <br />2001 <br />2002 <br />2003 <br />5500 FEE INCLUDES FACILITY FEE + 1 TANK - <br />($170) x („U„ksy <br />g170)X (9e .nks) <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $101 TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.561 FACILITY <br />PERMANENT CLOSURE — <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : CLOSURE FEE =.$279 /TANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Const uct m Inspections) <br />TANK ID;l (s) : -- - <br />PLAN CHECK FEE _ $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID #t (s): <br />$ <br />TANK RETROFIT REPAIR FEE _ $279 / FACILITY (use for monitoring equipment_ spill buckets. tank sumps. misc_) <br />>/ <br />PIPiNGREPAIR FEE =$279/FACILITY (use for piping under-clispenser containment, ect) <br />MISCELLANEOUS <br />$ <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR . <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />- ALL rCGJ HKC �KJr., vn � nG ».a nvvilL � nh. G � 1mc In/�) ua.ccu.a rrL.a rwu ..... u� u•- � . ._........_ - <br />OFFICE USE ONLY <br />nSERVICE 12EQUEST # FACILITY ID AMOUNT RECEIVED CHECK # RECEIVED BY DATE RECENED <br />SR <br />EH 23 032 (REVISED 8/01103) <br />