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AOUIN COUNTY ENVIRONMENTAL HEALTH D .RTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> � e <br /> FACIA NAME. FACILITY CONTACT NAME <br /> FACILITY ADDRESS SITE PHONE AREA CODE <br /> P, 6i Wd. d%7)i 20 <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> ICA Q 5 /. <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 /> -S.TOCKTON CA 95205 Closure' Instalatim Repair Retrofit <br /> Fv <br /> CTIVE FACILITY <br /> 1998 " 1999- 2000 2001 . 2002 2003 <br /> _ OOFEEINCLUDESFACIUTY FEE t i TANK- (st7o)x(m&dcj (svO).x(ma­) <br /> $125.PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED - <br /> TANK SURCHARGE_$101 TAMC <br /> STATE SURCHARGE FOR FACRITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.5G✓FACILITY $ <br /> - i <br /> .'•P ENT CLOSURE <br /> (Removal o PemuKed Ck>sure in Place - <br /> $ . <br /> TANK ID (s):. CLOSURE FEE=_$279 PTANK #TANKS X$279= <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID.#(s): TEMPORARY CLOSURE FEE_$2791 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 ft s) <br /> TANK.RETRORT REPAIR FEE _$279/FACILITY (use for mooring equipment sprM buckets,tank suinps,mise) <br /> $ <br /> PIPINGREPAIR FEE =$279/FACILITY (use forpiOnunder-fispeii cartai-L ect) <br /> MISCELLANEOUS ! <br /> TRANSFER FEE _ $20 $ <br /> t <br /> CONSULTATION FEE : = S 93/HOUR __T <br /> UNAUTHORIZED RELEASE EVALUATION FEE . _ $93/HOUR $ _ <br /> SAMPLING INSPECTION FEE = S 93/HOUR <br /> ALL FEES"ARE BASED ON THE 593 HOURLY RATE TIME THAT EXCEDS FEES PAID WLL BE BILLEDTO APPLICANT_ <br /> OFFICE USE ONLY 4 <br /> SERVIM REQUEST i FACAM ID AMOUNT RECEIVED-: CHECK S RECEIVED BY 047E RECEIVEDI <br /> SR <br /> E1123032 k <br />