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Feb 17 12 08:23a Reliable PetroleumA 209-845-8953 p.22 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />-TelePhone: (209) 468-3420 Fizz: (209) 468-3433 Web. wvw•w.s�gow ora/ell <br />FACILITY NAM <br />r , i T, L FACILITY CONTACT NAME <br />vel �'� ' %�i�L�l'� MCP e L'. <br />FACILITY ADDR SS <br />SITE PHONE #WITH AREA CODE <br />e~) 3�-7 /� 2d <br />CITY STATE <br />ZIP CODE # CA O TANKS AT Sf7E <br />� 952.E s-- 2- <br />APP"L�ICANT BILL NG� NAME APPLICANT CONTACT NAME <br />recAPPLICANT MAI NG ADDRESS L -e SCLI.1 cj,,e <br />APPLICANT PHONE WITH AREA CODE <br />clTY� 3G rS�sh /1�I' z�,q <br />STATE ZIP CODE CIRCLE WORK TO BE DONEI CONTRACTOR ICC # <br />� Closure Installation alr etrofit 2 SD S' <br />ACTIVE FACILITY <br />$500 FEE INCLUDES FACILITY FEE + Z TANK (2006-2007) 2006 2007 2008 2009 2010 2011 <br />$550 FEE INCLUD S FACILITY FEE + 1 TANK (2008-22019', <br />$125 PER TANK A TER FIRST TANK <br />TANK PENALTY Ac SESSED $ <br />TANK SURCHARGE = $15 /TANK $ <br />STATE SURCHAR E FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRArJI =$49,00/ FACILITY $ <br />PERMANENT CLO URE <br />Removal or Permitted Closure in Place <br />TANK ID # (s) : CLOSURE FEE _ $375 !TANK = $ <br />TEMPORARY CLQ URE # TANKS X $375 <br />Plan Review and Ir, ectionsf <br />TANK ID # (sj : TEMPORARY CLOSURE FEE = $375 / FACILITY <br />INSTALLATION PL N CHECK <br />Plan Check and Go (ruction inections <br />TANK ID # (s) : PLAN CHECK FEE _ $1,000 /FACILITY <br />REPAIR PLAN CHE K <br />TANK ID # (sj <br />TANK RETROFIT RE AIR FEE = $375 / FACILITY (use for monitoring equipment, cold Starts, EVR upgrades, $ <br />S ill buckets, sum s. misc. <br />PIPING REPAIR FEE $375 I FACILITY i use for piping, under -dispenser containment, ect.) 1317a, <br />FSAMPLING <br />S <br />$ 25 <br />FE _ $ 125/ HOUR $ <br />RE EASE EVALUATION FEE _ $ 125-1 HOUR $ <br />CTI N FEE: = S 925/ HOUR $ <br />ALL FEES ARE BASED QN THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED To APpucgNT, <br />i OTAL AnnQUNT DUE <br />OFFICE USE ONLY <br />SERVICE REQUEST # FACILITY ID AMOUNT RECEIVED CHECK # <br />RECENED BY DATE RECEIVED <br />EH 23 032 (REVISED 0811 11 by KFI <br />