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Jan 16 13 03:07p Reliable PetroleurnA 209-845-8953 p.6 <br /> SAN JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stdcktor4 CA 95202-3029 <br /> Telephone. (209)468-3420 Fax.(209)468.3433 Web.www.sigov.orz/ehd <br /> FACILITY NAM FACILITY CONTACT NAME <br /> FACILITYAD iSS SITE PHONE#W mAREA CODE <br /> �. <br /> 4STATE 99 qy�-a-Y3k <br /> CITY ZIP CODE *OF TANKS AT SITE <br /> CA. <br /> APPUCANTEIL ING NAME APPLICANT CONTACTNAME <br /> 1 <br /> APPLICANT ING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> y�s�S . s1�- 9Y�->q3 <br /> CITY S7A7E ZIP CODE CIRCLE WORK TO BE DONE CONTRACTO-A-- <br /> Closure Installation Re k ReVofit <br /> ACTIVE FACILI <br /> 2007 2006 2009 2010 2011 2012 <br /> 5500 FEE INCILL 3FS FACILITY FEE+1 TANK(2C07-2005) i <br /> S550 FEE INCLL DES FACILITY FEE+1 TANK(2009-2012) $ <br /> 3126 PER TANK AFTERFIRST TANK <br /> S <br /> TANK PENALn ASSESSED $ <br /> TANK SURCKAJ GE=$151 TANK <br /> $ <br /> STATE SURCH RGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.001 FACILITY <br /> PERMANENT OSURE <br /> Removal or Per (decd Closure in Place` $ <br /> TANK ID* s CLOSURE FEE=$3751 TANK *TANKS X$375= <br /> TEMPORARY OSURE <br /> (Plan Review a I Ins edions) $ <br /> TANK IC#fs): TEMPORARY CLOSURE FEE_$375 t FACILITY <br /> EINSTALLATLONLAN CHECK <br /> Check an orstruction Ins 'ons $ID*(s): PLAN CHECK FEE=$10001 FACILITY <br /> REPAIR PLAN HECK <br /> TANK ID*(s) <br /> TANK RETROF REPAIR FEE =S376 I FACILITY (use for monitoring equipment.oold starts.EVR upgrades. c <br /> ill buoRets,sum s.Irdsc. :J <br /> $ <br /> PIPING REPAI FEE =$3751 FACILITY use for i ' ,under-dis eraser cdhtainment act <br /> MISCELLANEC JS <br /> S <br /> TRANSFER FE = $25 <br /> CONSULTATI 4FEE _ $1251 HOUR <br /> $ <br /> UNALITHORIZE D RELEASE EVALUATION FEE = S 12511i0UR <br /> $ <br /> SAMPLING IN ECTION FEE _ $1251 HOUR <br /> ALL FEES ARE ED ON THE$125 HOURLY RATE. T/AE THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AIN UNT DUE $ <br /> OFFICE USE C LY <br /> SERVICE REQUI 5T# FACILITY ID AMOUNT REC9VED CHECK* RECEIVEDEY I DATE RECFJVED <br /> EH 23 032(REVI ED 04%3112 5T KF) <br />