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SAN Jn"gUIN COUNTY ENVIRONMENTAL HEALTH DF-'RTMENT <br /> UNDERGRC D STORAGE TANK PROGRAM FL -WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> LIP twi L-1� Id <br /> FACILITY ADDRESS SITE PHONE#WITR AREA CODE <br /> 1 qg5_ /L. <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA q <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 ?.000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)X(#tanks) ($170)X(#tanks) <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A 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): TEMPORARY CLOSURE FEE_$279 i FACILITY <br /> INSTALLATION Pt1&N CHECK –� <br /> (Plan Cheri and Construction Inspections) <br /> TANK ID#(s): --]:j:_ PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mist.) I <br /> $ i <br /> I <br /> PIPING REPAIR FEE =$279/FACILITY (use for piping,under-dispenser containment,ect.) I <br /> MISCELLANEOUS j <br /> TRANSFER FEE _ $20 $ i <br /> CONSULTATION FEE _ $93/HOUR $ I <br /> j � <br /> UNAUTHORIZED RELEASE EVALUATION FEE $ <br /> _ $93/HOUR j <br /> i <br /> SAMPLING INSPECTION FEE _ $93/HOUR <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. !. 1 <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK#— RECEIVED BY DATE RECEIVED <br /> SR � !EH 23 032(REVISED 8/01/03) I ! <br />