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Aug 17 09 10:16a Reliable PetroleumA 209-845-8953 p.9 <br /> 00 SAN JOAQIffN COUN-1 • <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Far:(209)468-3433 Web.www.sigov.org/e <br /> FACILITY NAME FACILITY CONTACT NAME <br /> A9-c-)4 4(5,8 m PM LL <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> 1-J95-5— S. A � wo- 99 d-oi 9yY �c/3� <br /> CITY STATE 71P CODE #OF TANKS AT SITE <br /> Stcck CA <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> Lliable Petroleum Sifry+ceS snc • �-ober+ arn�Iarf <br /> APPLICANT <br /> �N AILING ADDRESS APPLICANT <br /> pPHONE#WITH AREA CODE <br /> CITYSTATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTORICC# <br /> G' 0.Y 3 LG l Closure Installationepair-Retrofit 'SaS �J y�—t.(.'r <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2004.2007) 2004 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2009) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$15/TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.001 FACILITY $ <br /> PERMANENTCLOSURE <br /> Removal or PertMtted Closure in Place <br /> TANK ID#(s): CLOSURE FEE=$345!TANK #TANKS X$345= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK 10#(s): TEMPORARY CLOSURE FEE=$345 f FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): j PLAN CHECK FEE=$920/FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> TANK RETROFIT REPAIR FEE =$345!FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ I�n <br /> s ill buckets,sum s,mise. <br /> PIPING REPAIR FEE S3451 FACILITY $ <br /> (use for piping,under-dispenser containment,ect. <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $ 1151 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1151 HOUR $ <br /> SAMPLING INSECTONFEE $ <br /> SAEA5 <br /> HOUR <br /> SEDONTHE5115ORALLFEEHLY <br /> RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLK:ANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED CHECK# RECENED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 07101109) <br />