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• SAN d OUIN COUNTY ENVIRONMENTAL HEALTH D RTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME__ FACILITY CONTACT NAME <br /> U l k 13 Z- <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> 7Z r_KKK <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 - [8170)x lraa,ks _ <br /> (St7o)x(ata�dcsy <br /> $125 PER TANK AFTER FIRST TANK <br /> • TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE_$10/TALC $. <br /> STATE SURCHARGE FOR FACILITIES-NOT ALREADY ON INVEPII.ORY IN A CUPA PROGRAM=$17.W FACILITY $ <br /> , ,.tr.-rzEANENT CLOS <br /> -�_ <br /> Removal or Permitted Closure in Place <br /> TANK(D#(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 /> (Plan Check and Construction Inspections) <br /> TANK ID 4(s)• PLAN CHECK FEE $744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID!t(s): q <br /> TANK.RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equiprnent,sod Il buckets,lank sumps.misc.) $ 7 <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping.under�disperiser coritainment,ecL) $ <br /> _ I <br /> MISCELLANEOUS. <br /> TRANSFER FEE _ $20 + <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR <br /> i <br /> $ r <br /> SAMPLING INSPECTION FEE _ $93/HOUR f <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE_ TIME THAT EXCEEDS FEES PAID WILL BE BILLED 70 APPLICANT_ i <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECENED• CHECK w RECEIVED BY DATE RECEIVED . (I <br /> SR i <br /> EH 23 032(REVISED 8101/03) <br />