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SAN JJ&QUIN COUNTY ENVIRONMENTAL HEALTH UWARTMENT <br /> UNDERGR D STORAGE TANK PROGRAM W WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> r � I Z-1 —77Fn— <br /> ( -,)I I j /j, )kca am, <br /> FACALITY ADDRESS I SITE PHONE#Wj1TH AREA CODE <br /> OiA 'Aqq- 73 <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> CA <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 209) 461 -6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> STOCKTON CA 95205 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x(#tanks) ($170)x(#tanks) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> 'TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <br /> I STA t E SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PFOGRAM=$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): `s-EMPORdARY CLOSURE FEE_$279/FACILITY F <br /> INSTALLATION P CHECK <br /> (Plan Check and Cons€t c6on Inspections) <br /> €ANK ID#(s): PLAN CHECK FEE_$744/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK RETROFIT REPAIR FEE _$2.79/FACILITY (use for monitoring equipment,spill buckets,tank sumps,mi3c.) 1 <br /> $02 7 <br /> PIPING REPAIR FEE =$2''9/FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> i <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $93/HOUR _ $ <br /> UNAUTHORIZED RELEASE EVALUA TION 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 j <br /> SERVICE REQUEST FACILITY ID AMOUNT RECEIVED CHECK-0 4ECEIVED BY --I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 8101103) <br />