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Oct 26 12 09:56a Reliable PetroleumA 209-845-8953 p.6 <br /> 1 • <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Mein Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)46$-3433 Web: w <br /> ww .sj ov.o ehd <br /> FACILITY NAM FACILITY CONTACT NAME <br /> �t��rt tt^rtiD ��RCc � rnf�rvi C• ;lt f�a+ldhft <br /> FACILITY ADD SITE PHONE#WITH AREA CODE <br /> CRY STATE ZIP CODE to TANKS AT SITE <br /> S'}or'_ CA 95215 3 <br /> APPLICANT BIL ING NAME - APPLICANT CONTACT NAME <br /> el,�ct-t�l� Ise-�-vle,,,��•f� s��wui �. C�Larl.I:�i.�. Sa:>_t, �-z <br /> APPLICANT MA ING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 1143x1 esAv-,c-- 9 -20e1 &oLi— R3(up 3 <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTnR ICC# <br /> (A' G Closure Installation it Retrofit <br /> ACTIVE FAM <br /> $500 FEE INCLV IES FACILITY FEE+1 TANK(2DD7-2008) 2007 2008 2009 2010 2011 2012 <br /> $550 FEE INCLV ES FACILITY FEE+1 TANK(2009-2012) <br /> $125 PER TANK FTER FIRST TANK $ <br /> TANK PENALTY SSESSED $ <br /> TANK SURCHA E:$151 TANK $ <br /> STATE SURCH GE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENTCL ISURE <br /> Removal or Perm led Closure in Place <br /> TANK IDA(s): CLOSURE FEE=5375/TANK *TANKS X3375= $ <br /> TEMPORARYCL LSURE <br /> Plan Review and sections <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375/FACILITY $ <br /> INSTALLATION P N CHECK <br /> Plan Check and C nstruction inspections) <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY $ <br /> REPAIR PLAN CH ECK <br /> TANK ID_#(s) <br /> TANK RETROFIT I EPAIR FEE =$375/FACILITY (use for monitoring equipment,told starts,EVR upgrades, $ <br /> 5 ill buckets,sumps,miso.) <br /> PIPING REPAIR F =$3751 FACILITY use for I 'n ,underCis enser wniainment ea $ <br /> [SAMPLING <br /> CELLANEOUS <br /> NSFFJt FEE _ $25 $ <br /> NSULTATION F E _ $1251 HOUR $ <br /> UTHORIZED EASE EVALUATION FEE 1251 HOUR _ $ <br /> INSPE rjON FEE = S 1251 HOUR $ <br /> ALL FEE$ARE BASE ON THE 5126 HOURLY RATE. TME THAT EXCEEDS FEES PAID WILL SE BILLED TO APPLICANT. <br /> TOTALANIOUT WE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT REC NED CHECKk RECEIVED gy ���� <br /> EH 9 0.421REVI$ED1113112bylVI <br />