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May 31 12 09:35a Reliable Petroleun-A 209-845-8953 p.12 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202.3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:WWw.sieov.org/ehd <br /> FACILITY NAM I FACILITY CONTACT NAME <br /> - C I Ll )kKA er- <br /> FACILITY ADD ESS l SfTE PHONE#WITH AREA CODE <br /> `Y S < sfr t�10u�e. 9y q9y �-zLl3 <br /> CITY STATE 21P CODE 11 0 OF TANKS AT SITE <br /> CA q5'L/S 3 <br /> APPLICANT BI NONAM APPLICANT CONTACT NAME <br /> P tau <br /> APPLICANT M ING ADDRESS APPLK:ANT PHONE#WITH AREA CODE <br /> II�3L' rscsho-- ? �OOL4-9303 <br /> CITY STATE 23P CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installailo I Retrofit <br /> ACTIVE FACILI <br /> $500 FEE INCL ES FACILITY FEE+1 TANK(2007-2008) 2007 2008 2009 2010 2011 2012 <br /> $550 FEE IINCLU ES FACILITY FEE+1 TANK(2008.2012; <br /> $125 PER TANK FTFRFIRSTTANK $ <br /> TANK PENALTY SSESSED $ <br /> iANKSURCHA 3E=$15/TANK $ <br /> STATE SURCH GE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.110/FACILITY $ <br /> PERMANENTCL URE <br /> Removal or Per tted Closure in Place <br /> TANK ID#(s): CLOSURE F <br /> TEMPORARY CL ISURE EE=S375 r TANK #TANKS X$375= $ <br /> (Plan Review and s tions <br /> TANKID#(s): 11 TEMPORARY CLOSURE FEE=$375/FAQ LITY $ <br /> INSTALLATION PAN CHECK <br /> tan Check and C instruction ins 'ons <br /> TANK ID#(s): PLAN CHECK FEE=$1000/FACILITY $ <br /> REPAIR PLAN CH ECK <br /> TANK I D#(s) <br /> TANK RETROFIT EPAIR FEE _$3751 FACILITY (use for monXoring equipment.cold stads,EVR upgrades, $ <br /> spill buckets.sumps,misr) S•— <br /> PIPING REPAIR Ff E =$3751 FACILITY use for piping,mder-disoenser containnx%t ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION r EE = $1251 HOUR $ <br /> UNAUTHORIZED LEASE EVALUATION FEE = $1251 HOUR $ <br /> SAMPLING INSFEJTION FEE = $ 1251 HOUR $ <br /> ALL FEES ARE BAS ON THE$129 HOURLY RATE.MIRE THAT EXCEEDS FFES PAtO WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOU TDUE <br /> OFFICE USE ONLY <br /> SERVICE REQUEST FACIUTYID AMOUNTRECEIVED CHECK# I RECEIVED BY DATE RECEIVED <br /> EH 23 032(REVISED C W3M2 by KF) <br />