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Oct 02 08 11:38a Reliable Petroleum 209-845-8953 p.g <br /> SAN JOAQUIN COUNTY 0 <br /> ENVf1WNA4-,NTAL HEALTH DEPARTMENT, <br /> 600 East blain Street, Stockton,CA 952027-3079 <br /> Telephone: (209)468-3420 Far:(204)468-3433 Web:www.sigov.org!ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS. SITE PHONE#WITH AREA CODE <br /> Soo S. 961 9 "d -. <br /> CITY �1 STATE ZIP CODE *OF TANKS AT SITE <br /> -..5 (' G t— L Y� CA 9 S.�� �r' z <br /> APPLICANT <br /> BILLING NAME �+ APPLICANT CONTACT <br /> NAME <br /> (� 4 <br /> f.C�l�ab\t ��'- 'C C' vL)Yl J ty- t r. n C'�j"2 V�+ i )C'1r Y-\k C"- <br /> APPLICANT MAILING ADDRESS APPLICANT_PHONE#WITH AREA CODE <br /> S� fGLY� ,IY�G �C✓ Irt✓ / L C. <br /> CITY STATE ZIP CODE CIRCLE WORK TO SE DONE CONTRACTOR ICC At <br /> cog =CIInstal#atia Repair 'Retrofit �jLu1S1- l� <br /> ACTIVE FACILITY <br /> 2003 2004 2005 2006 2007 2008 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Piace <br /> TANK ID# s : CLOSURE FEE=$315[TANK #TANKS X$315= <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK kD#(s): TEMPORARY CLOSURE FEE=$3151 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s) : PLAN CHECK FEE=$840!FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315 1 FACILITY (use for monitoring equipment,cold starts.EVR upgrades, <br /> spill buckets,sumps.misc.) <br /> PIPING REPAIR FEE _$315 1 FACILITY use for piping,under-dispenser containment,ect. $-31S <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $2D <br /> CONSULTATION FEE = $1051 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 1051 HCU'R $ <br /> SAMPLING INSPECTION FEE = $ 1051 HOUR $ <br /> ALL FEES ARE BASED ON THE S9a HOURLY RATE TIME THAT EXCEEM FEES PAID WILL BE BILLED TO APPLICANT, <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY IDAMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 7P 8108) <br />