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' S QUIN COUNTY ENVIRONMENTAL HEALTH AbARTMENT <br /> LJNDERGR1WJND STORAGE TANK PROGRAM Mr= WORKSHEET <br /> L <br /> FACILITY NAME • _ <br /> FACILITY CONTACT NAME <br /> FACILITY ADDRESS <br /> SITE PHONE#VgM k9EA CODE <br /> tr lIY STATE <br /> ZIP :ODE #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 <br /> ( 209) 461-6337 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> STOCKTON CA 95205Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> 1998 1999 . 2000 2001 2002 2003 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK ($170)x( ksi ($170)x Ittsanksl _ <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE_$10/TANK $. <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$17.501 FACILITY $ <br /> 9 rv. :�* t4ENl i LtSS5F <br /> Removal or Permitted.Closure in Place _ <br /> TANK ID (s): CLOSURE FEE=-$279 PTANK #TANKS X$279= $ <br /> TEMPORARY CUJSURE <br /> Plan Review and Inspections) <br /> TANK I.D (s): TEMPORARY CLOSURE FEE_$279/FACILITY $ <br /> INSTALLATION PLAN CHECK ) <br /> (Plan Check and Construction Insne^tions) � r <br /> TANK tU#(s): PLAN CHECK FEE—$744%FACILITY c <br /> REPAIR PLAN CHECK <br /> i <br /> TANK ID-4(s): <br /> TANK RETROFIT REPAIR FEE _$279/FACILITY (use for monitoring equipment,spill buckets,tank sumps,misc.) $ " <br /> PIPINGREPAIR FEE _$279/FACILITY (use for piping.under4speriser containment,ecl) $ <br /> j <br /> MISCELLANEOUS_ j <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $93/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $931 HOUR $ E <br /> i <br /> $ <br /> SAMPLING INSPECTION FEE _ $931 HOUR i <br /> ALL FEES ARE BASED ON THE$93 HOURLY RATE- TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY + <br /> SERVICE REQUEST 0 FACILITY ID AMOUNT RECEIVED, CHECK# RECEIVED BY DATE RECEIVED t <br /> SR <br /> EH 23 032(REVISED 8101103) <br />