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Oct 23 09 06:14a Reliable Petroleu A 209-845-8953 p.6 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fix:(20 9)468-3433 Web:Ww—W-sg,ov_.orl1'ehd <br /> FACILITY NANIft FACILITY TACT NAM <br /> NE <br /> o- '5)2 <br /> FACILITY ADDRESS SITE PHONE#WRH AREA ODE <br /> SOS vi, (xf i vj20� 99 Z-1�3 <br /> CITY ST TE ZIP CODE #OF TANKS AT SITE <br /> S CA 9s <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> PCINOtrum rEF-E-r <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#YVITH AREA CODE <br /> 933Cp <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> O Qyle— l� j 3(P Closure Installation. <br /> epalr)Retrof t 5 2ts'j) yy f.-Vi, <br /> ACTIVE FACILITY <br /> 7 <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) 2004 2005 2006 2002008 2009 <br /> 5550 FEE INCLUDES FACILITY FEE+1 TANK <br /> 5125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=5151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S49.001 FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s : CLOSURE FEE=$3451 TANK #TANKS X$345= $ <br /> TEMPORARY CLOSURE <br /> Ian Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$3451 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> rPlan Check and Construction Ins actions <br /> TANK ID#(s): PLAN CHECK FEE_$920 1 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE _$345!FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $3L1S <br /> spill buckets,sumps.mist. .7 <br /> PIPING REPAIR FEE =$3451 FACILITY use for pIpIng.under-dispenser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE _ $1161 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1151 HOUR $ <br /> SAMPLING INSPECTION FEE = $1151 HOUR $ <br /> ALL FEES ARE BASED ON THE$11514OURLY RATE. TINE THAT EXCEEDS FEES PAID VWLL RE BILLED TO APPLCAHT. <br /> OFFICE USE ONLY <br /> SERVtCERECUEST# I FACILITYID I AMOUNT RECEIVED CHECK I RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED W101I09) <br />