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SAN JC -1UIN COUNTY ENVIRONMENTAL HEALTH D'- \RTMENT <br /> UNDERGRO .D STORAGE TANK PROGRAM F. . WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> Ccs bO C7 �G n c <br /> FACILITY ADDRESS SITE PHONE#WIT EA CODE <br /> V-1 11 c . usem) V-e— 20 ) 3 - y -� ► S <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> ry-\ c ct CA 9 SS C) s <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 /> 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 !$170)X(#tanks) ($170)X(wanks) <br /> 125 PER TANK AFTER FIRST TANK <br /> - -- I $ — <br /> TANK PENALTY ASSESSED <br /> j TANK SURCHARGE=$10/TANK <br /> i STATE SURCHARGE FOR FACILITIES N�:-f ALREADY ON INVENTORY INA CUPA PROGRAM=$17.50/FACILITY <br /> ` PERMANENT CLOSURE - <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): - --__yT EMPORARY CLOSURE FEE=$279/FACILITY-- -I $ ---� <br /> F2NSTALLATION PLAN CHECK - --- — —.__---- <br /> (Plan Check and Construction Inspections) <br /> ANK ID#(s): PEEN CHECK FEE=$744/FACILITY $ <br /> r. <br /> dE`'AIR PLAN CHECK -— -- <br /> - <br /> [_LANK;o#(s): ------- --- - - <br /> $ i <br /> I .i ANK RETROFIT REPAIR FEE =$279/FACILITY fuse for monitoring equipment,spill buckets,tank sumps,mist.) <br /> PIPING REPAIR FEE =$279/FACILITY----- (use for piping,under-dispenser cx1ntainment,ect.) <br /> MISCELLANEOUS — — �-�-- <br /> = l � <br /> IRANSFER FEE $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $93/HOUR <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEE PAID WILL BE BILLED TO APPLICANT. <br /> i <br /> OFFICE USE ONLY ; <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED � <br /> SR L I <br /> EH 23 032(REVISED 8/01/03) <br />