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SAN JO IN COUNTY ENVIRONMENTAL HEALTH DFjj&1RTMENT <br /> UNDERGROMb STORAGE TANK PROGRAM FMWVVORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> C C),c, � <br /> FACILITY ADDRESS SITE PHONE#WITH AJMA CODE <br /> C) ci <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CAq'—s� a !t <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 I 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(#tanks) <br /> $125 PER TANK AFTER FIRST TANK —tet <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ — <br /> STATE SURCHARGE f'OR FACILITIES NOT ALR LADY ON INVENTORY IN A CUPA PROGRAM 17.50/f_ACI L.ITY <br /> PERM ENT 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 Inspecti(jns) _ <br /> r ANK ID#(s) j TEMPORARY CLOSURE FEE_$2-19/FAC .'YY <br /> INSTALLATION PLAN CHECK — <br /> ,Plan Check.and Construction Inspections) <br /> t. Nir iD#(s): $ <br /> i PLAN CHECK FELE_$744/FACILITY <br /> RE,AIR PLAN CHECK — — <br /> S <br /> TANK ID#(s) <br /> I TP NK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mise) <br /> Pli,I11(,REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> ` <br /> MISCELLANEOUS <br /> g TRANSFER FEE _ $20 <br /> CONSULTATION FEE _ $93/HOUR <br /> y <br /> UNAUTHORIZED RELEASE EVAt.I_)ATION FEE _ $93/HOUR $ <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. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8101/03) <br />