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' SAN AMQUIN COUNTY ENVIRONMENTAL HEALTHRTMENT <br /> Y UNDERGR ND STORAGE TANK PROGRAM F WORKSHEET <br /> FA NAME FACILITY CONTACT NAME <br /> FA DRESS S P1464EITN AREA CODE <br /> 1 <br /> r r <br /> CfTY STATE ZIP CODE # F TANKS AT SITE <br /> CA <br /> JjLLLLj <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 <br /> ( 209) 461-6337 <br /> CITY =CA952 <br /> DE CIRCLE WORK TO BE DONE: <br /> STOCKTON 05 Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> ()9s 1999 . 2000 2001 200,"? <br /> chi I <br /> $500 FEE INCLUDE,`��e-ACiLI Imo!�t:.P=+1 TA^aK-- ($5?p;x,..�ank� �^ <br /> $125 PER TANK AFTER FIRST TANK ,� l��xol (tttanksy i <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$10/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.50/%AGILITY <br /> PERMANENT CLOSURE <br /> rNa*novdl or Permitted-Closure in Race)- <br /> TANK ID#(s): CLOSURE FEE_$279/TANK #TANKS X$279_ $ <br /> TEMPORARY CLOSURE —-- <br /> (Pian Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$279/FACILITY $ — <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction inspections) <br /> 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,mise) <br /> PIPING REPAIR FEE _$279/FACILITY (use for piping,under-dispenser containment,ect.) $ i <br /> MISCELLANEOUS <br /> TRZANSt`„-R FEE _ $2C1 <br /> CONSULTATION FEE — $93/HOUR $— <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $93/HOUR $ <br /> $ i <br /> SAMPLING INSPECTION FEE _ $93/HOUR j <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. I <br /> ii <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED: CHECKS RECEIVED BY DATE RECEIVED <br /> I <br /> — �. <br /> SIR <br /> EH 23 032(REVISED 8101103) <br /> i ,lll <br />