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a <br />SAN I&QUIN COUNTY ENVIRONMENTAL HEALTHRTMENT <br />ro UNDERGR ND STORAGE TANK PROGRAM *WORKSHEET <br />FACT NAME <br />FACILITY CONTACT NAME <br />APPLICANT MAILING ADDRESS <br />% <br />2535 WIGWAM DRIVE <br />FACIL ADDRESS <br />SITE PHONE # WffH AREA CODE <br />e <br />CITY STATE <br />E <br />rCfl if 7CA <br />ZIP CODE # OF TANKS AT SITE <br />J <br />95205 <br />ELITE IV CONTRACTORS, INC_ <br />APPUGANT CONTACT NAME <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />2002 <br />2003_. <br />(209) 461-6337 <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />STOCKTON CA <br />95205 <br />Closure Installation Repair Retrofit <br />ACTIVE <br />.$500F EE -INCLUDES FACILITY FEE + 1 TANK_- <br />$125 PER TANK AFTER FIRST TANK <br />l <br />1998 <br />(Svo)x (#ta�k�) <br />1999 <br />(si7o)x tma j <br />2000 _ <br />2001 <br />2002 <br />2003_. <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$ <br />ALL FEES ARE BASED Cw THF Cwt unuDI v Dare neee n..T r.. __. _ _ _ - <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />[TANK SURCHARGE _ $10 /TANK <br />$ <br />TATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM=$17.SG7 FACILITY <br />$ <br />PERMANENT -CLOSURE <br />Removal ar Pem;itted Closure in Place <br />TANK IDP (s) : CLOSURE FEE _ $279 / TANK # TANKS X $279 = $ <br />TEMPORARY CLOSURE — <br />(Plan Review and Inspections) <br />TANK ID 4 (s) : TEMPORARY CLOSURE FEE _ $279 / FACILITY <br />I INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) . <br />TANK ID # (s) <br />kRFP_A1R PIAN CHEEK <br />D #! (s): <br />ETROFIT REPAIR FEE _ $279 / FACILITY (use for rn <br />REPAIR FEE = $279 / FACILITY (use for pi{ <br />PLAN CHECK FEE _ $744 / FACILITY <br />R <br />$ ... <br />t, spill buckets, tank sumps, mise.) <br />;ercontainment ectl $ - <br />)us. –� <br />i TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 93/ HOUR - <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 931 HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />$ <br />ALL FEES ARE BASED Cw THF Cwt unuDI v Dare neee n..T r.. __. _ _ _ - <br />OFFICE USE ONLY <br />SERVICE REQUEST # <br />SR <br />EN 23 032 (REVISED 8/01 <br />