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Oct 13 11 05:05p Reliable PetroleumA 209-845-8953 p.6 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALThI DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web:www.sjgoY.om,'ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> G W i!y`t�l'I u '(✓l e Sat'..i ` <br /> FACILITYADD SS SITEPHONE#WITH AREACODE <br /> ;56 ja� gf z-/7 t <br /> CITY STATE ZIP CODE #OF TAN KS AT SITE <br /> L CA15� j <br /> APPLICANT BI ING E APPLICANT CON ACT NAME <br /> f L Ali, 1 1 Sai <br /> APPLICANT MA LIN G ADDRESS APPLICANT P NE#VPI AREA CODE. <br /> !V1 �S <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE I CONTRACTOR ICC# <br /> Closure Installation Repak Retrofit <br /> ACTIVE FACILI <br /> 2006 2007 2008 2009 2010 2011 <br /> $500 FEE INCLI. DES FACILITY FEE+1 TANK(2006-2007) <br /> S560 FEE INCLI. DES FACILITY FEE+1 TANK(2008-2011) <br /> 5125 PER TANK kFTER FIRST TANK $ <br /> TANK PENALTY rSSESSED $ <br /> TANK SURCHA GE=$15/TANK $ <br /> STATE SURCH GE FOR FACILITIES NOT ALREADY ON INVENTORY INA CUPA PROGRAM=$49.001 FACILITY $ <br /> PERMANENT Cl SURE <br /> Removal or Pert iitted Closure in Place <br /> TANK ID# s CLOSURE FEE=$375 i TANK #TANKS X$375= $ <br /> TEMPORARY Cl OSURE <br /> Plan Review an Ins actions <br /> TANK ID#(s): TEMPORARY CLOSUR=FEE=$375/FACILITY $ <br /> INSTALLATION ILAN CHECK <br /> Plan Check and bonstruction Ins edons <br /> TANK ID#(s): PLAN CHECK FEE=$1,0001 FACILITY $ <br /> REPAIR PLAN C iECK <br /> TANK ID#(s): <br /> TANK RETROFI REPAIR FEE _$375 GILITY (use for monitoring equipment,cold starts,EVR upgrades. $ <br /> spill buckets,sumps.miscl <br /> PIPING REPAIR EE_$375 7 FACILITY use for piping,under-dispenser containment act. <br /> MISCIELLANEOLIIS <br /> TRANSFER FEE = S25 $ <br /> CONSULTATION FEE = S 125/HOUR $ <br /> UNAUTHORIZEE RELEASE EVALUATION FEE = S 1251 HOUR $ <br /> SAMPLING INSP -CTION FEE = S 125/HOUR $ <br /> ALLFEESAREB ED ONTRE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. O <br /> TOTAL AMCI INT DUE <br /> OFFICE USE ON Y <br /> SERVICEREQUESFACILITY ID I AMOUNTRECEIVED ! CHECK# RECEIVED BY I DATE RE <br /> # CEIVED <br /> EH 23 032(REVIS 0911111 by KFI <br />