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SANUIN COUNTY ENVIRONMENTAL HEALTH RTMENT UNDERGR D STORAGE TANK PROGRAM FTE WORKSHEET FACILITY NAME FACILITY CONTACT NAME a CARRIE MILLER FACILITY ADDR SS SITE PHONE # WITH AREA CODE It cf 7)Ivy `,- v -% -5 CITY STATE ZIP C DE # OF TANKS AT SITE SCA"i I CA �j I APPLICANT BILLING NAME APPLICANT CONTACT NAME ELITE IV CONTRACTORS, INC. CARRIE MILLER APPLICANT MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE 2535 WIGWAM DRIVE (209) 461-6337 CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: Closure Installation Repair Retrofit STOCKTON CA 95205 ACTIVE FACILITY TANK ID # (s) : - 1998 1999 2000 2001 2002 UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR $500 FEE INCLUDES FACILITY FEE + 1 TANK ($170) X (#tanks) ($170) X (#tanks) 12003 $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 PERMANENT CLOSURE Removal or Permitted Closure in Place TANK ID # (s) : CLOSURE FEE= $279 /TANK # TANKS X $279 = TEMPORARY CLOSURE (Plan Review and Inspections) TANK ID # (s) : TEMPORARY CLOSURE FEE = $279 i FACILITY ALLATION PLAN CHECK i Check and Construction Ir TANK ID # (s) : PLAN CHECK FEE = $744 / FACILITY REPAIR PLAN CHECK TANK ID #t (s): TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) $ 1' PIPING REPAIR FEE = $279 / FACILITY (use for piping, under -dispenser containment, ect.) MISCELLANEOUS TRANSFER FEE --- $ 20 — ---- _ CONSULTATION FEE _ $ 93/ HOUR UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR SAMPLING INSPECTION FEE = $ 93/ HOUR ALL Ptt, AKC DROMU VM Inn- 4,7/5 r1VURLY RAI G I6AM 1 rll11 ww- GIC --u - w--m- OFFICE USE ONLY ID I AMOUNT RECEIVED SR EH 23 032