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SAN QUIN COUNTY ENVIRONMENTAL HEALTH RTMENT <br /> UNDERGRND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILI NAME( FACILITY CONTACT NAME <br /> V . <br /> FACILITY ADDRESS SITE P O #WITHCODE <br /> 1u - 17 <br /> CIT1( 1STATE ZIP CODE #OF TANKS AT SITE <br /> CA j <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ELITE IV CONTRACTORS, INC. CARRIE MILLER <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2535 WIGWAM DRIVE <br /> ( 209) 461-6337 <br /> CffY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> STOCKTON CA 95205 <br /> Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003_ .: <br /> _-$50A FEE-INCLUDES FACILITY FEE-r.i TAI RE", (s»o)x #tan -- <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$101 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/FACILITY $ <br /> PERMANENT CLOSURE — <br /> Removal or Permitted Closure in Place' <br /> TANK ID#(s): CLOSURE FEE=$279/TANK #TANKS X$279= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_.$279/FACILITY" $ <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s):. 7—PLAN CHECK FEE_$744%FACILITY $ <br /> REPAIR PIAN CHECK <br /> TANK ID#(s): <br /> $ i <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mise.) j <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ect.) <br /> i <br /> MISCELLANEOUS .! <br /> TRANSFER FEE <br /> $20 <br /> CONSULTATION FEE _ $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR - <br /> $ <br /> ii <br /> SAMPLING INSPECTION FEE _ $93/HOUR $ j <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE:BIt_LED TO APPLICANT: <br /> OFFICE USE ONLY i ! <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE.RECENED <br /> SR f � <br /> EH 23 032(REVISED 8101/03) <br />