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SAN JOAOUIN COUNTY ENVIRONMENTAL HEALTH DOf2TMENT <br /> UNDERGROUND STORAGE TAMK PROGRAM FEE WORKSHEET <br /> FACES NAJAE FACIL CONTACT NAME <br /> FACI SITE E#WITH AREA CODE <br /> 06 9 <br /> CITYSTATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> ELITE IV CONTRACTORS, INC_ CARRZE 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' Installafim Repair Retrofit " <br /> ACTIVE FACILITY <br /> 1998 " 1999 - 2000 2001 . 2002 2003- <br /> .. ._._.-..... .., - _ • <br /> $�_00 FEE.IN CLUDES FACILITY FEE+.I TANK - (svommanks) (svo)x(mesas) <br /> ( $125.PERTANKAFTERRRSTTANK $ <br /> TANK PENALTY ASSESSED - <br /> $ <br /> TANK SURCHARGE=$101 TANK <br /> $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVEWORY IN A COPA PROGRAM=$17.5G/FACILITY <br /> ..:> "PERMANENTCEOSGRE <br /> ernovat or Pemutted Closure in Pace <br /> $ . <br /> TANK ID#(s): CLOSURE FEE=-$279/'TANK #TANKS X$279= _ - <br /> TEMPORARY CLOSURE ! <br /> (Plan Review and Inspe ons) <br /> i <br /> $ <br /> TANK ID.#(s): TEMPORARY CLOSURE FEE_$279:/FACILITY . <br /> INSTALLATION PLAN CHECK <br /> (Pian Check and Constnicbm Inspections). <br /> TANK ID;#(s): PLAN CHECK FEE_.$744%FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID# s) <br /> $ <br /> TANK-RETROFIT REPAIR FEE _$2791 FACILITY (use for mmixing equipment spill buckets,tank sumps,misc.) <br /> PIPING-REPAIR FEE =$279/FACILITY (use for piping:under-dspeiiser coidainmenL ecL) <br /> Q 79i <br /> MISCELLANEOUS t <br /> $. , <br /> TRANSFER FEE _ $20 <br /> 'CONSULTATION FEE : = S 931 HOUR _ <br /> UNAUTHORIZED RELEASE EVALUATION FEE . _ $93/HOUR <br /> $ <br /> $ r <br /> SAMPLING INSPECTION FEE = S 93/FLOUR I <br /> i <br /> ALL FEES'ARE BASED ON THE$93 HOURLY RATE_ TVAE THAT EXCEEDS FEES PAID WILL BE BILLED"TO APPLICANT_ <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ED AmouNT CHECK# BY GATE RECEIVED : <br /> SR . <br /> EH 239 301M) <br />