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Mar 31 09 11:30a Reliable PetroleumA 209-845-8953 p.51 <br /> SAID JOAOUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telepleoue:(209)468-3420 Fax..(209)468-3433 web:wy.��'.si�ay.oTgLehd <br /> FACILITY NAME FACILINe-i sh Po tcTY CONTACT NAME <br /> MIDI 1r APfi <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY S, a ��LI�SDYI P�55 90 X30- T7`7 r1 <br /> CITY STATE <br /> ZIP CODE #OF TANKS AT SITE <br /> CA ?5 <br /> 3& <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> l�b <br /> APPLICANT lIAAlL1NG ADDRESS �r+APPLICANT PHONE#WITH AREA CQDE <br /> so do 9 <br /> C(I�TY STATE ZIP CODE CIRCLE WORK TO BE DONE 1 CONTRACTOR ICC# <br /> 95-3[p 1 Closure InstaIlati Repair Retrofit <br /> °��� S,�soy5_j-u <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) 2004 2005 2006 2007 2008 2009 <br /> $550 FEE INCLUDES FACILfTY FEE+1 TANK f2C'�0' <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY 1N A CUPA PROGRAM X24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ID# s CLOSURE FEE_$3151 TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_ $3151 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Inspections) <br /> TANK ID#(s): PIAN CHECK FEE_$8401 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$315(FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> —Ell buckets,sum s,mist. S. <br /> PIPING REPAIR FEE _$315/FACILITY use for piping,under-dispenser containment,eat. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = S 105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = S 1051 HOUR $ <br /> SAMPLING,INSPECTION FEE = S 105/HOUR $ <br /> ALL FEES ARE BASED ON THE$105 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL 9E 81LLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> =23032RIREVISED <br /> EST# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> EH 02123109) <br />