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SANUIN COUNTY ENVIRONMENTAL HEALTH*WORKSHEET <br />RTMENT <br />UNDERGROND STORAGE TANK PROGRAM <br />FACILI NAME <br />FACILITY CONTACT NAME <br />t I AL & <br />4f <br />� 0 o n vA, <br />FACIL ADDRESS <br />SITE PHONE # I AREA CODE <br />(209) 461-6337 <br />CITY <br />STATE <br />CITY <br />STATE <br />ZIP CODE <br /># OF TANKS AT SITE <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 />(209) 461-6337 <br />CITY <br />STATE <br />ZIP CODE <br />CIRCLE WORK TO BE DONE: <br />Closure Installation Repair Retrofit <br />STOCKTON <br />CA <br />95205 <br />ACTIVE FACILITY <br />TANK ID # (s) : <br />CLOSURE FEE = $279 /TANK <br />1998 <br />1999 <br />2000 <br />2001 <br />2002 <br />2003 <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK <br />(5170) X (#tanks) <br />($170) X (#tanks) <br />$125 PER TANK AFTER FIRST TANK <br />$ <br />$ <br />1 TANK PENALTY ASSESSED <br />TANK SURCHARGE = $10 / TANK <br />$ t <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 Platz) _ <br />TANK ID # (s) : <br />CLOSURE FEE = $279 /TANK <br /># TANKS X $ ?79 - <br />TEMPORARY CLOSURE <br />(Plan Review and Inspections) _ <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $2791 FACILITY _- <br />ALLATION PLAN CHEC <br />i Check and Construction <br />TANK ID # (s) : I PLAN CHECK FEE = $744 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID#1 s): <br />TANK RETROFIT REPAIR FEE = $279 / FACILITY (use for monitoring equipment, spill buckets, tank sumps, misc.) <br />- <br />PIPING REPAIR FEE =$279/FACILITY (use for piping, under -dispenser containment, ect) <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />MISCELLANEOUS <br />TRANSFER FEE _ $20 - <br />20 -CONSULTATION <br />CONSULTATION FEE _ $ 93/ HOUR <br />UNAUTHORIZED RELEASE EVALUATION FEE = $ 93 / HOUR <br />SAMPLING INSPECTION FEE = $ 93/ HOUR <br />is <br />ALL:•CCJ AKC DAJCY VM Ir7C a7J nUWMLI Kfil C. IimI a"l I GAIiGGYJ f CGJ rN✓ .ILL caL ca�LLc.Y �v ry ��viv� <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVEDCHECK # RECEIVED BY DATE RECEIVED <br />SR <br />EH 23 032 (REVISED 8/01/03) <br />