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0 <br />SANd&QUIN COUNTY ENVIRONMENTAL HEALTHRTMENT <br />UNDERGR *WORKSHEET <br />ND STORAGE TANK PROGRAM <br />— — ' 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 />Crit( STATE ZIP CODE CIRCLE WORK TO BE DONE: <br />STOCKTON CA 95205 Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />FAQM� CONTACT NAME®�_%' <br />$`,Q0 FFE ?$:CLUDFS FACILITY �" I:E + 1 TANK -- <br />1998 <br />($170) X (Aanks) <br />1999. <br />(5170) x (#t3Ncs) <br />2000 <br />2001 <br />2002 2003 <br />. <br />o $125 PER TANK AFTER FIRST TANK <br />• rOF <br />TANKS AT SITE <br />— — ' APPLICANT CONTACT NAME <br />ELITE IV CONTRACTORS, INC. CARRIE MILLER <br />APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br />2535 WIGWAM DRIVE <br />( 209) 461-6337 <br />Crit( STATE ZIP CODE CIRCLE WORK TO BE DONE: <br />STOCKTON CA 95205 Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />$`,Q0 FFE ?$:CLUDFS FACILITY �" I:E + 1 TANK -- <br />1998 <br />($170) X (Aanks) <br />1999. <br />(5170) x (#t3Ncs) <br />2000 <br />2001 <br />2002 2003 <br />. <br />o $125 PER TANK AFTER FIRST TANK <br />TANK PE NALTY ASSESSED <br />i <br />TANK SU RGfiXR(;F =t J 0 / 1 ANt <br />9 <br />^`a I_ ` URCHAkGE FOR FA(-: tiITIES NOT <br />PERMANENT CLOSURE <br />aMO I or Permitted-Ciosure in Piace)� <br />TANK 11) # (s) <br />T(w MPM- . Y CLOSURE <br />(Pear, R izw and Inspections) <br />TANK ID 4, (sl : <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Ir <br />TANK ID # (s) <br />ON INVEN FORY IN A CI K),A PIROGRIAM =$17.50/ _ Auidl ' <br />C L O a URE FEE $279 / TANK # TANKS X $279 = i $ <br />TEMPORARY CLOSURE FEE _ —$2 -7 -9 -1 - <br />FACILITY $ <br />PLAN CHECK FEE _ $744 / FACILITY $ I <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK.RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />PIPING "REPAIR FEE = $279 I FACILITY (use for piping, under -dispenser containment, Oct) <br />MISCE EOUS . <br />?RAt'1c 1 7 e> 2" <br />CONSULTATION FEE _ $ 03/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR $ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR $ <br />ALL FEES ARE BASED ON THE $93 HOURLY RATE_ TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACDLITY lD AMO!!NT RE CEIVED CHECK # RECEIVED BY nnTr RPP-;: I; <br />