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S QUIN COUNTY ENVIRONMENTAL HEALTH RTMENT <br />UNDERGR ND STORAGE TANK PROGRAM FEE WORKSHEET <br />FA ILI J Y NAME ^� <br />FACILITY CONTACT NAME <br />ELITE IV CONTRACTORS, INC_ <br />CARRIE MILLER <br />FACILITY ADDRESS <br />SITE PHONE #WITH AREA CODE <br />- <br />Ln <br />- <br />CRY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />OL <br />CA <br />5� <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC_ <br />CARRIE MILLER <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />(209) 461-6337 <br />CITY <br />STATE <br />ZNP CODE <br />CIRCLE WORK TO BE DONE: <br />Installation Repair Retrofit <br />-STOCKTON <br />CA - - <br />95205aosure` <br />pk%.1 IV rAWu17 <br />. <br />TANK ID # (s) : <br />CLOSURE FEE =-$279 PTANK <br />1998 <br />1999. <br />2000 <br />2001 <br />2002 <br />2003 <br />$ <br />. $500 FEE INCLUDES FACILITY FEE +.1 TANK - <br />(s»o)x (ur dm) <br />I$»ot x tsunksl <br />q- <br />_ ....... . <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />r <br />t TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE _ $101 TANK <br />$. <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.501 FACILITY <br />$ <br />PERMANENT CL05tiFtE — <br />Removal or Permitted aosure in Place) <br />TANK ID # (s) : <br />CLOSURE FEE =-$279 PTANK <br /># TANKS X $279 = <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE _ $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />TANK ID # (s) : PLAN CHECK FEE $744 / F� <br />REPAIR PLAN CHECK <br />TANK ID # (s): <br />TANK.RETROFIT REPAIR FEE _ $279 / FACILITY (use for monitain6 equipment, spill buckets, tank <br />PIPING REPAIR FEE =$279/FACILITY (use for s*in2 under-6snerlser rnmtainmPnt Pel <br />MISCELLANEOUS <br />ON THE <br />TRANSFER FEE _ $ 20 <br />$ I <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />ALL FEES -ARE BASED <br />$ <br />j <br />i <br />rr <br />S93 HOURLY RATE TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. i <br />f.: <br />OFFICE USE ONLY <br />SERVICE REQUEST 9 FACILJTY ID AMOUNT RECI VED CHECK # RECEIVED BY DATE RECENVED <br />SR <br />cu n." iomnccr. eIn-, <br />