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Aug-07 12 03:09p Reliable PetroleumA 209-845-8953 p.6 <br /> 0 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> aO East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 F=(209)469-3433 Web.-yLww.s�gov.org/ehd <br /> FACILITY N E — <br /> -- VA TYTY CON NAME <br /> WE <br /> ON <br /> '5 Kal <br /> FA CIU A ESSSITE PHONE*WITH/AREAffCODE <br /> - <br /> CITY <br /> STATE ZIP—CODE #OF TANKS AT SITE <br /> CA 1y!53q1,) <br /> APPILICANT BI fw NAME I APPLICANT—c--o-&TACT <br /> WA--ME <br /> APAPPLICANTlilt j'[LIWG-—ADDRESS APPLICANT PHONE III WITH AREA 666—E <br /> CITY STATE 21P CODE <br /> ----CIRCLE"—WORK TO BE DONE CONTRACTOR ICC# <br /> GBi� 17-, Closure Installation Re it Retrofit <br /> —ACTIVE—FAC(Lr Y— <br /> 20+37 2008 2D00 <br /> $500 FEE INCL L DES FACILITY FEE+I TANK(2007-2008) 2010 2011 2012 <br /> $550 FEE INCL t DES FACILITY FEE+1 TANK(2009-2012) --- <br /> $125 PER TANK AFTER FIRST TANK <br /> $ <br /> TANK PENALTY SSESSED <br /> � <br /> TANK SURCHA E=S151TANK $ <br /> Sj <br /> C <br /> URC GEF R FACILITIES NOT ALREADY <br /> STATE SURC E FOR FACILITIES NOT ALREADY ON INVENTORY IN A CLIPA PROGRAM--S49,00i FACILITY <br /> PERMANENT C URE <br /> (Removal or Pe itted Closure in Place) <br /> TANK 10!ts . CLOSURE FEE- <br /> TEMPORARY CL OSURE <br /> (Plan Review and IMections) <br /> TANK ID*(s): TEMPORARY CLOSURE ir ACIUTY <br /> NSTALLATION I ILAN CFI <br /> jPian Check and onstruction Inspections) <br /> TANK IE)#(s): PLAN CHECK FEE $1000 FACILITY <br /> 1 REPAIR PLAN ail!ECK <br /> TANK ID*(s). <br /> TANK RETROFIT EPAIR FEE =$375/FACILITY (use for monitoring equipment,Gold starts,IDJR upgrades, $ <br /> L-PIPING REPAIR F-=E $375 J FACILITY .......(use for pOing,under-dispenser containment,ed,) 1;-75— <br /> MISCELLANEOUI <br /> TRANSFER FEE $25 $ <br /> CONSULTATION I EE = $1251 HOUR <br /> I UNAUTHORIZED RELEASE EVALUATION FEE = q:195/HOUR $ <br /> SAMPLING INSPETION FEE = S 1251 HOUR $ <br /> ALL <br /> L FEIEE5SARE BAS 0 ON THE 125 HOURLY RATE, TIME THAT EXCEEDS FEES PAID V"LL BE BELLED IU—APPUCAW. <br /> TOTAL AMOU T DUE 7 <br /> OFFICE <br /> FFICE USE ONL <br /> AMOUNT SERVICE REQUEST i t FACILITY it) 907:U ED -1-CHECK It RECEWM13Y I [W-r—ERE <br /> CEVEo <br /> Ell 23 032—(REVISED 13112 by <br />