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SAN AhQUIN COUNTY ENVIRONMENTAL HEALTH EftRTMENT <br />UNDERGRMND STORAGE TANK PROGRAM FM WORKSHEET <br />'FACILiTY NE <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />fTY CONTACT NAME <br />(Aw h)_IF <br />FACILf'ry ADDRESS <br />2535 WIGWAM DRIVE <br />(09) 461-6337 <br />sPRONE ITH AREA CODE <br />_r; <br />I fiF CODE <br />CIRCLE WORK TO BE DONE: <br />Closur6* Installation Repair Retrofit <br />M) <br />C X <br />% <br />95205 <br />STATE <br />CA <br />- 1 #0 TANKS AT SITE <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 />(09) 461-6337 <br />CITY <br />STATE <br />I fiF CODE <br />CIRCLE WORK TO BE DONE: <br />Closur6* Installation Repair Retrofit <br />STOCKTO I N, <br />CA. <br />95205 <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE+ 1 TANK <br />$125 PER TANK AFTER FIRST TANK <br />1998 <br />($170)X(Manks) <br />1999 <br />($170),x m6anks) <br />2000 <br />2001 <br />2002 <br />2003 <br />$ <br />SAMPLING INSPECTION FEE $ 93/ HOUR <br />All FXFq mpg: RAIM"m TUC taw un - <br />TANK PENALTY ASSESSED <br />TANK SURCHARGE = $10 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.501 FACILITY <br />$ <br />(Removal or Permitted Closure in Place) <br />TANK ID # (s): <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (sl: <br />CLOSURE FEE =1279TANKS X $279 <br />REPAIR PLAN CHECK <br />TANK ID 4 (s): <br />TANK RETROFIT REPAIR FEE $279 FACILITYI (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />72 1 <br />PIPING REPAIR FEE = $2791 FACILITY (use for piping, under4spe, ' er containment ect) <br />$ <br />MISCELLANEOUS <br />TRANSFER FEE $20 <br />CONSULTATION FEE $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE $93/HOUR <br />$ <br />SAMPLING INSPECTION FEE $ 93/ HOUR <br />All FXFq mpg: RAIM"m TUC taw un - <br />OFFICE USE ONLY <br />SER <br />SIR VICE REQUEST A <br />EH 23 032 (REVISED 8101103) <br />-FAMOUNT REcErvED, I rmpmc's' <br />(ID <br />RECEIVED BY DATE RECEIVED <br />