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S OUIN COUNTY ENVIRONMENTAL HEALTH TMENT <br /> UNDERGR ND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACE' NAM FACILMfPONTACT NAME <br /> FA ADD <br /> srWPhdNt# A CODE <br /> 'aL 1�_c9k(D <br /> STATE ZtP CODE #OF TANKS AT SITE <br /> _T CA <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 56N—E- <br /> N­ <br /> ONE:N CA 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 . 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+9 TANK - grro>x1#lanksj p7olx(rttanks) _ <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=$17.501 FACILITY $ <br /> Pfe=itMANENT CLOSv UR^'— ---- <br /> Removal or Permitted Closure in Place <br /> TANK(D/1(s): CLOSURE FEE=.$279 PTANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#t(s): TEMPORARY CLOSURE FEE_$279/FACILITY 1$ <br /> INS ON PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> _ _ ., _«-- ' -- - — - __ -ter- _ - • -�-- - __._ <br /> TANK ID 4(s): - $ <br /> PLAN CHECK FEE $744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID 4(s): <br /> TANK.RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) $ <br /> PIPING REPAIR FEE =$279/FACILITY (use for piping.under-disperiser containment,ect) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ t <br /> CONSULTATION FEE _ $931 HOUR - $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR $ <br /> i <br /> SAMPLING INSPECTION FEE _ $931 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 a RECEIVED BY DATE RECENED <br /> i.. <br /> SR <br /> EH 23 032(REVISED 8101103) <br />