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SANUIN COUNTY ENVIRONMENTAL HEALTH DOTMENT UNDERGRO ND STORAGE TANK PROGRAM FEE WORKSHEET FACILITY NAME FACILITY CONTACT NAME Q.o �, CARRIE MILLER FACILITY ADDRESS SITE PHONE # WITH ARE"C DE rCtiC- J c.� c 3 CITY STATE ZIP CODE # OF TANKS AT SITE STOCKTON CA 952D5 APPLICANT BILLING NAME APPLICANT CONTACT NAME ELITE IV CONTRACTORS, INC. CARRIE MILLER APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2535 WIGWAM DRIVE (2 9) 461-6337 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: ,Closure Installabon Repair Retrofit STOCKTON CA 952D5 ACIIVL FAGILIIY - .:. TANK RETROFIT REPAIR FEE _ $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, mist.) 20dt7 27601, 2002 2003 ` - FEE INCLUDES 'Au LJTY FEE + I TANK - (Sl 70) X (#tanks) ($170) X (otants) E $125 PER TANK AFTER FIRST TANK TANK PENALTY ASSESSED $ $ TANK SURCHARGE •= $10 / TANK STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY $ (Removal or Permitted Closure in Race). $ TANK ID # (s) : CLOSURE FEE =.$279 PTANK # TANKS X $279 = TEV,?ORARY CLOSURE ;_Plan Review and Inspec t xis $ TANK iD # (s) TEMPORARY CLOSURE FEE _ $2791 FACILITY INSTALLATION PLAN CHECK (Plan Check and Construction Inspections) TANK ID # (s) : PLAN CHECK FEE _ $744 / FACILITY REPAIR PLAN CHECK TANK ID # (s): TANK RETROFIT REPAIR FEE _ $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, mist.) $1 / PIPING REPAIR FEE = $279 / FACILITY (use for piping, underAispenser containment, ecL) $ CONSULTATION FEE _ $ 931 HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / SAMPLING INSPECTION FEE _ $ 93/ HOUR ALL FEES ARE BASED ON THE.493.HOU.RLY RATE. TIME THAT OFFICE USE ONLY SERVICE REQUESTS FACILITY ID AMOUNT RECENED CHECK C -RECEIVED BY, DATE RECEMED SR EH 23 032 (REVISED 8101/03)