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SAN JC IN COUNTY ENVIRONMENTAL HEALTH DEMENT <br />UNDERGRO D STORAGE <br />TANK PROGRAM FE WORKSHEET <br />ACILITY NAME FACILITY CONTACT NAME <br />�� `� .5'� <br />TY ADDRESS SITE PHONE TH AREA CODE <br />[IFMALI <br />1AJ llrr ,� <br />—CODE <br />fTY STATE ZIP # OF TANKS AT SITE <br />f� <br />APPLICANT BILLING NAME APPLICANT CONTACT NAME <br />ITE IV CONTRACTORS, INC_ CARRIE MILLER <br />CANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />F2535 <br />WIGW AMM DRIVE <br />(209 461-6337 <br />CITY <br />STATE ZIP CODE CIRCLE WORK TO BE DONE: <br />STOCKTON CA 95205 <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />1999 �n � -�r�r� � _r ' 0- r <br />($1731X(YNanks) - (S?0)X%#tanks) ? . <br />f $125 PER TANK AFTER FIRST TAW <br />$ <br />t4l. <br />TANK PENALTY ASSESSED $ --- <br />TANK SURCHARGE = $10 / TANK $ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY <br />$ <br />IN A CUPA PROGRAM =$17.50/ FACILITY <br />- <br />_...... _.. s <br />PE ,ANENT CLOSURF, <br />(Removal or Pemitted Closure ir. Puce` <br />FTANK ID # (s) : CLOSURE FEE _ $279 / TANK # TANKS X $279 = $ <br />EMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : PLAN CHECK FEE _ $744 /FACILITY $ <br />REPAIR PLAN CHECK <br />TANK ID # (sj <br />TANK RETROFIT REPAIR FEE _ $279 / FACILITY (use for monitoring equipment$ — <br />spill budce(s, tank sumps, mist.) <br />j <br />PIPING REPAIR FEE _ $279 / FACILITY (use for piping under-dispenser containment, ect) $ <br />_--------- <br />MISCELLANEOUS <br />i <br />TRANSFER FEE $ ?Q <br />CONSULTATION FEE _ $ 93/ HOUR i $ <br />UNAUT H ORIZED RELx ASE EVALUX iON FEE - y W / HC3UR <br />S <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR $ <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE, TIMF 1-f{AT EXCEFDS TEES PAI® SE 5i1,ED TO AF1 i LAW. <br />I <br />l + <br />OFFICE USE ONLY <br />ESRs E REQUEST8':. FAC1Lrry ID AMOUNT RE - CHE( 0RECEIVEDBY <br />I - <br />EH 23 032 (REVISED 8101/03) <br />r <br />i <br />