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SAN�QUIN COUNTY ENVIRONMENTAL HEALTH I*RTMENT <br />UNDERGR LUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />APPLICANT MAILING ADDRESS <br />E c 1 :r <br />FACILITY ADDRESS <br />SrrE PHONE # WITH AREA CODE <br />C - <br />STATE <br />CITY <br />STATE <br />ZIP CODE <br /># OF TXNKS AT SITE <br />P c c <br />CA <br />C, <br />$ <br />APPLICANT BILLING NAME <br />ELITE IV CONTRACTORS, INC.ti' <br />APPLICANT CONTACT NAME <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 />Closure' Installation Repair Retrofit <br />STOCKTON <br />CA <br />95205 <br />REPAIR PLAN CHECK <br />$ 00 FEE INCLUDES FAUUTYFEE +I TANK - <br />$125 PER TANK AFTER FIRST TANK <br />($170)X(Awks) <br />1999 <br />(S170) X (Manks) <br />2(100 1 <br />2001 <br />2032 <br />! 200 <br />1 . <br />$ <br />1 <br />TANK PENALTY ASSESSED <br />$ <br />i� <br />TANK SURCHARGE = 510 / TANK <br />$ <br />_ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />$ <br />P12RMANENr LO{t7 is y' <br />`Removal or Permitted Closure in Place - <br />TANK ID # (s) : <br />CLOSURE FEE =.$279 /TANK <br /># TANKS X $279 = <br />TEV. PORARY CLOSURE <br />;Plan Review and Inspes5x-s <br />$ <br />T/ -NK iD # (s) : TEMPORARY CLOSURE FEE _ $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : <br />PLAN CHECK FEE _ $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK IDJ7 (s): <br /># <br />TANK RETROFIT REPAIR FEE _ $279 /FACILITY (use for monitoring equipment, spill buckets, tank sumps, mist.) <br />ftp <br />PIPING REPAIR FEE = $279 / FACILITY (use for piping, under�disperiser containment, ecL) <br />$ <br />1 <br />TRANSFE7< FEE _ $ LCi <br />CONSULTATION FEE = $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE =$93/HOUR. <br />SAMPLING INSPECTION FEE _ $ 9W HOUR <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APF <br />OFFICE USE ONLY <br />TT <br />SERVICEREQUEST # FACILITY ID AMOUNT RECEIVED . ' CHECK <br />u. w....- I--ww —.. ..., <br /># <br />RECEIVED BY DATE RECEIVED <br />SR <br />u. w....- I--ww —.. ..., <br />