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Jun 10 09 04:54p Reliable PetroleumA 209-845-8953 p.9 <br /> SAN JOAQUiN COUR'TY 0 <br /> EwiRONINIENTAL HEALTH DEPARTmsNT <br /> 600 East Main Street Stockton,CA 95202-3029 <br /> Telenkolle:(209)468-3420 Frame(209)468-3433 Web:wwW.g&o ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> G �c� <br /> FACILITY ADDRESS SITE PHONE#WI H!AREA CODE <br /> CITY15- (Al • f f`�� <S�t`�� do Of 4'3 CI—If 93 <br /> 9 <br /> :ATE TJP CODE #of TANKS AT SITE <br /> ��c� e 9s 37 � '3APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> :j <br /> El 1 b1 e__ <br /> �'�t�� �u �v',(, JJ 1 <br /> APPUCAMT MAILING ADDRESS e ark' <br /> ,�J APPLICANT PHIONE#WITH!AREA CODE <br /> 3`L1 I� 90 q Q '1- ?3 3 <br /> CtT1' STATE ZIP CODE WORK T�BEIDO�NEI ICC#`' �" <br /> �%A�KULM <br /> llation <br /> ffACTIVE FACILITY <br /> EF_INCLUDES FACIUTY FEE+1 TANK(2003-2008) 2Q� 20173 201 6 2p07 2008 2Q0�EE INCLUDES FACILITY FEE+1 TANK( i n <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=s15 t TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM x$24.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK O# s CLOSURE FEE_$3151 TANK $ <br /> TEMPORARY CLOSURE #TANKS X$316 <br /> Plan Review and Ins eettons <br /> TANK ID#{s): TENIPgRARY CLOSURE FEE_$3151 FACIUTY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Consuuctlon Ins eciions <br /> TANK ID <br /> PLAN CHECK FEE_$8401 FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s} <br /> TANK RETROFIT REPAIR FEE _$315 f FACILITY ( <br /> use for monitoring equipment,cold starts,EVR upgrades, <br /> s iI! buckets, <br /> SUMS.misc. <br /> PIPING REPAIR FEE _$315/FACILITY $ <br /> fa'PiDino.under-dis eraser containment,ect•) J� <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $ 1051 HOUR $ <br /> UNA117 HORI2I=D RELEASE EVALUATION FEE = $1051 HOUR $ <br /> SAMPLING tNSPCCTION FEE = $105f HOUR $ <br /> ALL FEES AREQN THE$105 HOURLY RATE TIME THAT EXCEEDS FEES PAW WILL BE B&LEUs 7®APPa.6CAprp <br /> QFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY!a ---UNT RECEIVED <br /> CHECK# REGENED BY DATE RECIJVED <br /> SR <br /> EH 23 032(REVISED OZr23/09) <br />