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Mar 30 12 02:27p Reliable PetroleurnA 209-845-8953 p.6 <br /> SAN JOAQUIl\COUNTY <br /> ENVIRONMENTAL.HEALTH DEPARTvIE]N 1- <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fur:(209)469-3433 Web:www.s oy or /ehrl <br /> FACILITY NAM <br /> FACILITY CONTACT NAME <br /> K�-1 sharmst <br /> FACILITY ADD SS <br /> SITE PHONE#WITH AREA CpDE <br /> CIJrYvL� 1�L I A If 7 <br /> STATE ZIP CODE <br /> CA #OF TANKS AT SITE <br /> 5.33 G 3 <br /> APPUCANT BIL ING NAME <br /> APPLICANT CONTACT NAME <br /> el; P�fr�l�;�,� sej1 �S �C• GK�d�IL <br /> APPLICANNTTMM A! VL <br /> ING ADDRESS <br /> APPUCANT PHONE#WITH AREA CODE <br /> 1 30 rse.sit o c 44. <br /> CITY � Sys- k5 gl<� <br /> STATE ZIP CODE CIRCLE WORK TO 9E DONE <br /> 11 CSF 93 3 CP CONTRACTOR ICC# <br /> I Closure Installation epai Retrofit -zsC <br /> ACTIVE FACILI <br /> $500 FEE INCLUD S FACILITY FEE 4. 1 TANK(2006-2007) 2006 2007 2008 2009 2010 2011 <br /> $550 FEE INCLUD S FACILITY FEE+1 TANK(2008-2011 i <br /> $125PERTANKAJ ER FIRST TANK <br /> $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARG =S151 TANK $ <br /> STATE SURCHARC E FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.0f)t FACILITY $ <br /> I <br /> PERMANENT CLO URE <br /> Removal or Perrnitt d Closure in Plane <br /> TANK ID# s CLOSURE FEE=$375(TANK $ <br /> TEMPORARY CLO RE #TANKS X 3375= <br /> Plan Review and In ectiors <br /> TANK 1D#(s); TEMPORARY CLOSURE FEE_$375/FACILITY $ <br /> INSTALLATION PU N CHECK <br /> (Plan Check and Co trucfion Ins ections) <br /> PLAN CHECK FEE_$7 QQp/FACILITY <br /> REPAIR PLAN CHE <br /> TANK ID#(s): - <br /> TANK RETROFIT RE IAIR FEE =$3751 FACIL17Y (use for monitoring equipment, cold starts, EVR upgrades, $ <br /> d D <br /> spill buckets sumps.mise. ��j <br /> PIPING REPAIR FEE $3751FACUTY S <br /> I (use for pipin under-dispenser Containment,act) <br /> MISCELLANEOUS <br /> TRANSFER FEE S 25 <br /> $ <br /> CONSULTATION FEE _ $ 125!HOUR <br /> $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $125 1 HOUR <br /> SAMPLING INSPECTI I N FEE = S 1251 HOUR <br /> ALL FEES ARE BASED CN THE$125 HOURLY RATE. TIME THAT EXCEEDS Fi:ES PAID WILL BE S11,LED 70 APPLICANT. $ <br /> TOTAL AMOUNT UE <br /> OFFICE U5E ONLY $ 37 S r <br /> SERVICE REQtlES7# FACILITY ID <br /> AMOUNT RECEIVED I CHECK# RECEIVt3p BY DATE RECEIVED <br /> EH 23 032 tRFV1cFn <br />