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SAWMQUIN COUNTY ENVIRONMENTAL HEALTI RTMENT <br />UNDERGMFND STORAGE TANK PROGRAM E WORKSHEET <br />Ac1 e T NAME <br />APPLICANT CONTACT NAME <br />FACT CONTACT NAME <br />rFA <br />APPLICANT MAILING ADDRESS <br />:1PZHON <br />ITY ADDRESS <br />2002 <br /># WITH AREA CODE <br />�y <br />ITY (•t <br />® <br />T��® <br />ZIP CODE# OF TANKS AT SITE <br />r <br />95205 <br />I <br />CAL <br />rr�� <br />W®1 <br />$ <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 />2002 <br />2003 <br />(209) 461-6337 <br />CITY STATE <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />STOCKTON CA <br />j <br />95205 <br />I <br />1 - - -- <br />Closure Installation Repair Retrofit <br />ACTIVE FACILITY <br />TANK ID # (s) : CLOSURE FEE = $279 / TANK # TANKS X $279 = <br />$500 FEE INCLUDES FACILITY FEE + I TANK <br />$125 PER TANK AFTER FIRST TANK <br />1998 <br />($»o>x (#zwks) <br />1999 <br />($»ol x(manks) <br />2000 <br />2001 <br />2002 <br />2003 <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE _ $10 / TANK <br />_$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />$ <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 />-TEMPORARY <br />TANK ID # (s) : <br />CLOSURE FEE = $279 / FACILITY <br />INSTALLATION PLAN CHECK <br />(Plan Check and Construction Inspections) <br />—T --TANK ID # (s) : PLAN CHECK FEE _ $744 /FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # s) <br />TANK RETROFIT REPAIR FEE _ $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />$pl <br />PIPING REPAIR FEE = $2791 FACILITY (use for piping, under -dispenser containment, ect) <br />$ <br />MISCELLANEOUS - <br />ID <br />TRANSFER FEE _ $ 20 <br />CONSULTATION FEE _ $ 93/ HOUR <br />$ <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE _ $ 93 / HOUR <br />$ <br />SAMPLING INSPECTION FEE _ $ 93/ HOUR <br />------, <br />TMF S03 L1l111D1 v n Ax n1= n -------- <br />$ <br />ALL FEES ARE BASED C>"1 <br />OFFICE USE ONLY <br />SERVICE REQUEST <br />SR <br />EN 23 032 (REVISED 8/01 <br />ID AMOUNT RECEIVED CHECK # I RECEIVED BY <br />