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Apr 02 12 11:52a Reliable Petroleu 209-845-8953 <br />p.6 <br />SAN JOAQUIN COUNTY <br />ENVIRONTMEN'T AI. HEALTH DEPARTMEP <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 408_3420 Fax: (209) 468-3433 Web: wutiv.sji ov.ore%hd <br />FACILITY NAME <br />FACILITY CONTACTl�IAME <br />ri <br />FACILITY A00REiS <br />SITE PHONE #WITH AREA CODE <br />x'33 <br />CITYSTATE <br />ZIP CODE <br /># OF TANKS AT SITE <br />CA la <br />3 <br />APPPUCANT BILL! G NAME APPLICANT CONTACT NAME <br />9d �j, <br />io <br />APPLICANT <br />('iTI�D't� Llj'V i S PYV i C� S SIG. A Sa n alle Z <br />MAILI <br />G ADDRESS APPLICANT PHONE # WITH AREA CODE <br />1030 <br />rs �s� i� �(, d6- I l�U �1-- 93 00 3 <br />CITY <br />STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR iCC # <br />c ' `!5 <br />PI Closure Installation Re air Retrofit 52 <br />c� <br />ACTIVE FACILITY <br />e <br />$500 FEE INCLUDE <br />FACILITY FEE + i TANK (2006-2007) <br />2006 2007 <br />2008 2009 2010 2011 <br />$550 FEE INCLUDES <br />FACILITY FEE + 1 TANK (2008-2011) <br />$125 PER TANK AF <br />R FIRST TANK <br />TANK PENALTY AS ESSED <br />$ <br />TANK SURCHARGE <br />= $15! TANK <br />$ <br />STATE SURCHARG <br />FOR FACILITIES NOT ALREADY ON INVENTORY IN n rI IDA ®cnn®Ap. <br />S <br />TANK ID # (s) : <br />RE <br />CLOSURE FEE — $375! TANK # TANKS X 5375 I $ <br />= $3751 FACILITY <br />TANK ID # PLAN CHECK FEE = $1,000 I FACILITY <br />REPAIR PLAN CHE . <br />a <br />TANK ID —#I' s) : <br />TANK RETROFIT RE 1R FEE = $375 f FACILITY (use for monitoring equipment, raid starts, 'EVR upgrades, $ <br />Mill buckets sum s, mise. 7 S <br />PIPING REPAIR FEE $375 / FACILITY (use for ipin , under -d' ensercaontainment, ect.) $ <br />MISCELLANEOUS <br />ER FEE _ $ 25 <br />TATION FEE I = $1 <br />= $1 <br />TOTAL AMOUNT UE <br />OFFICE USE ONLY <br />� 3�JS,— <br />