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/ SAN JOAQUIN COUNTY EWRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FA NAME, FAC:iLITY NTACT NAME <br /> r <br /> FAC _ SITE PHON WITH ARE ODE <br /> CRY. STATE ZIP CODE 0 OF TANKS AT SITE <br /> CA <br /> APPLICANT BALING NAME <br /> APPLICANT CONTACT NAME <br /> CARRIE MILLER <br /> ELITE IV CONTRACTORS, INC_ <br /> APPLICANT d1AlUNG ADDRESS APPLICANT PHONE S WITH AREA CODE <br /> 253S WIGWAM DRIVE ( 209) .461-6337_ <br /> CF" STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> STGCiCTOiv LES 95205 Closw4e Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 . 2000 2001 2002 2003 <br /> $ 0 FEE lNCL1JDES FACILITY FEE+1 TANK . (si70)x(aw+�aj$500 <br /> S125 PER TANK AFTER FIRST TANK $ <br /> r - <br /> $ <br /> TANK PENALTY ASSESSED <br /> TANK SURCHARGE=$101 TANK $ <br /> STATE SURCHARGE FOR FACAITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.5C✓FACILITY <br /> -� isEiZMAHENT CL(}SURE <br /> emoval or Permitted Closure in Place <br /> $ . <br /> TANK ID (s):. CLOSURE FEE=.5279 f TANK S TANKS X$279= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspecfias) $ <br /> TANK ID S(s). TEtIpORARY CLOSURE FEE=$279:/FACILITY . <br /> INSTALLATION PLAN CHECK <br /> (Pian Check and Consb uction Inspections) <br /> TANK ID FEE $744 l FACILITY <br /> REPAIR PLAN CHECK <br /> TANK IDS s) <br /> TANK.RETROFTT REPAIR FEE =$2791 FACILITY (use tkx rnordxmg equipment spill buckets.tank skmiPs.mrsc) <br /> PIPfNG'REPAIR FEE _$279/FACILITY (use for opir W wxier-dsper ser cora 'L ecL) <br /> - t <br /> UtSCELLANEOUS- <br /> TRANSFER FEE = $20 <br /> -CONSULTATION FEE : = S 93/HOUR $ --T <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $931 HOUR. $ <br /> SAMPLING INSPECTION FEE = S 93/HOUR ) <br /> ALL F{F5 31RE BASED ON THE S93 HOURLY RATE TWE THAT EXCEEDS FEES PAID WILL BE B11 I EDTO APPLICANT- <br /> OFFICE USE ONLY i <br /> l <br /> r—";,RR <br /> FACILITYm AMIOUNTit5CFNED CHECK R- <br />