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SAN JUIN COUNTY ENVIRONMENTAL HEALTH DEMENT <br />UNDERGROOD STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />APPLICANT CONTACT NAME <br />FACILfTY CONTACT NAME <br />LS. <br />\ c\ _'�> <br />FACILITY ADDRE\S(S�- <br />(209) 461-6337 <br />SITE PHONE # WIIN AREA <br />STATE <br />`y <br />^CODE <br />CITY <br />CA- <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />v G c <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. <br />TANK.RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />(209) 461-6337 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closured Installation Repair Retrofit <br />STOCKTON <br />CA- <br />95205 <br />REPAIR PLAN CHECK <br />ACTIVE FACILITY <br />TANK ID # (s): <br />TANK.RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$F00FEEINCLUDESFA,.iUTYrEE+1TANK <br />$125 PERTANK AFTER FIRST TANK <br />I <br />(Snn,;;tnc:,nks} <br />1999 <br />($170)X(Otaks) <br />2000 <br />2%.1- <br />'2002 <br />ICCs <br />-. <br />$ <br />- <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $10 /TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />PERkiANENT .�0•t7i:E <br />(Removal or Permitted Closure in Place <br />TANK ID # (s) : <br />CLOSURE FEE =.$279 /'TANK <br /># TANKS X $279 = <br />! $ <br />TEk"?ORARY CLOSURE <br />;Plan Review and insper1-XIS) <br />Tf NK iD # (s} <br />TEMPORARY CLOSURE FEE _ $279 / FACILITY <br />$ <br />INSTALLATION PLAN CHECK <br />Plan Check and Constriction Inspections) <br />TANK ID # (s) : <br />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, misc.) <br />_2 <br />PIPING REPAIR FEE =$279/FACILITY (use for piping under4speriser containment, ecL) <br />$ <br />MISCELLANEOUS <br />1 <br />"i RANSFER FES W "` <br />I CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />Aff FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE Bit I TO AF <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY 1D AMOUNT RECEIVED <br />CII W WJ4 lrw-vt.JW Div llw4) <br />CHECK <br />RECEIVED BY DATE RECENSD <br />SR <br />CII W WJ4 lrw-vt.JW Div llw4) <br />