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SOAOUIN COUNTY ENVIRONMENTAL HEALTH D ARTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACIE (eY NAME _ <br />FACILITY CONTACT NAME <br />ELITE IV CONTRACTORS, INC— <br />CARRIE MILLER <br />FACRITY ADDRESS <br />SiFE PHONE S WVH AREA CODE <br />253S.WIGWAM DRIVE <br />(209).461-6337 <br />CfTY <br />STATE <br />ZIP CODE <br />S OF TANKS AT SITE <br />� y.SLUB . <br />CA <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC— <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS . <br />APPLICANT PHONE 9 WITH AREA CODE <br />253S.WIGWAM DRIVE <br />(209).461-6337 <br />CITY I STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Rep2i-v Retrofit " <br />-STOCKTON CA'- <br />� y.SLUB . <br />ACTIVE FACIilTY7-7 <br />or. - Ckra,re in Place -- <br />TANK ID # (s) : <br />1998" <br />1999- <br />2000 <br />2001 _ <br />2002 <br />2003- <br />(Ptare Review ankf inspeciEorss) <br />_ $!.00 FEE INCLUDES FACILITY FEE:,, 1 TAhtiG- <br />TANK tD-� (s}: <br />TET�IPORARY CLOSURE FEE= 3279:/ FACILITY - <br />SS25.PER TAW AFTER FIRST TANK <br />` <br />$ <br />TANK PENALTYASSESSED <br />- <br />$ <br />TANK SURCHARGE _ $10 / TANK <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON MWORY.INA CUPA PR=$17.5G/ FACILITY <br />P CLOStiRE <br />or. - Ckra,re in Place -- <br />TANK ID # (s) : <br />PLAN CHECK FEE =. $7441 FACILITY <br />TANKRETRORT REPAIR FEE _ $279 / FACILITY (use for marring equipment, sprTl-buckets, tank sumps. mist) <br />TANK ID 0 (s) = . <br />CLOSURE FEE =_5219 i7AAlIC <br /># TANKS X $274= <br />TENIPO RARY CLOSURE <br />(Ptare Review ankf inspeciEorss) <br />TANK tD-� (s}: <br />TET�IPORARY CLOSURE FEE= 3279:/ FACILITY - <br />INSTALLATION PLAN.CHECK <br />(Pfau► Check and Construction I_rmpections) " <br />TANK ID # (s) : <br />PLAN CHECK FEE =. $7441 FACILITY <br />REPAIR CHECK <br />TANK ID 7(s): <br />TANKRETRORT REPAIR FEE _ $279 / FACILITY (use for marring equipment, sprTl-buckets, tank sumps. mist) <br />PIPtNGREPAIRFEE =$279/FACILITY (useforpolg:und--, spe7isercoistairunenLecL) <br />-MAISCELLANEOUS = t <br />TRANSFER FEE _ $ 20 <br />— - $ <br />CONSULTATION FEE : = S 93/ HOUR _ T <br />LNAUTHOROM RELEASE EVALUATION FEE . _ $ 93 / HOUR $ <br />SAMPLING MPECTION FEE = S 93/ HOUR <br />r <br />ALt FIEES-ARE BASEDCH THE $93 HOURLY RATE_ TRAEE THAT EXCEEDS FEES PAID WLL BE 1391ED"TCS APPLICANT_ 1 <br />OFRCE USE ONLY Is <br />SERVICE REQUEST i FACILITY 113 AMOUXT RECEIVED CHECK II REcevEDBY D&TE RECEIVIEDI <br />