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SAN JO IN COUNTY ENVIRONMENTAL HEALTH DF�TMENT <br /> UNDERGROSTORAGE TANK PROGRAM F�f11VORKSHEET <br /> FACILITY, AME FACILITY CONTACT NAME <br /> V wo a , <br /> FACILITY ADDRESS tJ/ a SITE PHONE#WITH AREA CODE <br /> 3L4d�o- <br /> 1/L l Jo l <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA (A v l <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 STATE I ZIP CODE CIRCLE WORK TO BE DONE: <br /> STOCKTON CA -- J95205 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 -- <br /> -- -- I $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK <br /> $ <br /> S i':♦TE SURCHARGE FOR FACILITIES NOT i,!_7Cir:ADY ON INVi:Ni ORY INA 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 /> A`_K I-J#(s): TEMPORARY CLOSURE FEE_$279/FACILITY <br /> — <br /> -"LLATION PLAN CHECK <br /> (Pan Che.k and Construction Inspections) <br /> TANK ID;;is): PLAN CHECr,FEE_$744/FACILITY <br /> REPOk,PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.)_ <br /> PING REPAIR FEE =$279/FACILITY fuse for piping,under-dispenser containment,ect.) <br /> i :MISCELLANEOUS <br /> l'RA.NSi"i=R FEE _ $20 <br /> $ <br /> .;;LlNSULTAl-ION FEE _ $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION 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# FACILITr ID AMOUNT RECEIVED CHECK.# RECEIVED BY DATE RECEIV il <br /> SR <br /> EH 23 032(REVISED 8/01/03) <br />