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AQUIN COUNTY ENVIRONMENTAL HEALTH ARTIMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACT i i Y NAME . <br />FACILITY CONTACT NAME <br />C�C_ ` \e�` i ! \', 8 <br />CARRIE MILLER <br />FACILITY ADDRESS <br />SITE ONE # WffK A CODE <br />,2,3 `) -57 <br />(209).461-6337. <br />CRY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />1 C, <br />CA_ <br />95205 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC_ <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PRONE # 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 />-STOCKT-ON <br />CEH ' <br />95205 <br />ACTIVE FACILITY <br />TANK ID # (s): CLOSURE FEE =_$279 /TANK <br />!t TANKS X $279 - <br />1998- <br />1999. <br />2000 <br />2001. <br />2002 <br />2043- <br />_ $yflD FEE.INCLUDES FACILITY FEE + I TANK - <br />(st7o) x ( } <br />(snO).x (amts) <br />- <br />( $125.PERTANKAFTERFIRSTTANK <br />TANK PENALTY ASSESSED <br />- <br />TANK SURCHARGE _ $101 TAMC <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON IWENTORY IN A CUPA PROGRAM=$17.5GI FACILITY ' <br />PERMANENT CLOSGKE <br />emavat or.Peffnitted Closure in Place ''- - <br />TANK ID # (s): CLOSURE FEE =_$279 /TANK <br />!t TANKS X $279 - <br />TEMPORARY CLOSURE <br />(Plan Review and kmpeclions) <br />TANK ID.# (s): <br />TEMPORARY CLOSURE FEE _ $279:/ FACILITY . <br />INSTALLATION PLAN CHECK <br />(Plan Check and Constntcfion Inspections) . <br />" TANK ID # (s) : <br />PLAN CHECK FEE ..$744 / FACILITY <br />REPAIR PIAN CHECK - <br />TANK fD 9 s): <br />TANK -RETROFIT REPAIR FEE _ $279 / FACIUTY (use for ffmA ring equipment. spilt buckets. tank suinps. mist.) <br />PIPINGREPAIR FEE = $279 / FACILITY (use for piping wxW-4spenser eattaeruner►t. ect.) <br />.. t <br />MISCELLANEOUS . <br />TRANSFER FEE _ $ 20 <br />"CONSULTATION FEE : _ $ 931 HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE . _ $ 93 ! HOUR . <br />- $ I <br />SAMPLING INSPECTION FEE = S 93/ HOUR <br />' ALL FEES"ARE. BASH ON THE $93 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TOAPPLICANT_ j <br />OFFICE USE ONLY t <br />sERvwE REauEsT # FACAM ID AMOUNT RECEIVED atEac # 'RECEIVED BY QkMIZECEIIt <br />SR f <br />Si 23032 (REIRSED WDIX i t <br />