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Dec 05 11 05:31p Reliable PetroleumA 209-845-8953 <br />p.6 <br />SAN JOAQUIN COUNTY 0 <br />ENVIRONIvICNTim, HEA1,T1-I DEPARTIvfENT <br />600 East Main Street, Stockton, Cil 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sieov ort0ehd <br />ILITY NAME <br />ffFAC1LITYADL;Rti;;S <br />FACILITY CONTACT NAME <br />aS� <br />V "(- 2 F'ie- I'th Ah I L <br />SITE PHONE #WITH AREA CODE <br />CITY <br />STATE ZIP CODE # OF TANKS AT SITE <br />APPLICANT BILI -fl <br />G NAME APPLICANT CONTACT NAME <br />ia.ble <br />'ol Sero; c es =me. u a,1 Sanr �z. <br />APPLICANT MAILIlaskoe <br />ADDRESS APPLICAN�VHUNL # WITH AREA CODE <br />I Rab <br />as oq- 93f� 3 <br />CIxX <br />75 <br />STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR IGC * <br />Closure lnstaflation epair Retrofit Z: <br />ACTIVE FACILITY <br />$500 FEE INCLUDE <br />FACILITY FEE+ 1 TANK (2006-2007) <br />2006 <br />2007 <br />2008 2009 <br />2010 <br />2011 <br />$550 FEE INCLUDE <br />FACILITY FEE + 1 TANK (2008-2011) <br />$ <br />$125 PER TANK A ER FIRST TANK <br />TANK PEINALTYAS <br />ESSED <br />$ <br />TANK SURCHARGE <br />= $151 TANK <br />$ <br />STATE SURCHARG <br />FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$49.001 FACILITY <br />$ <br />PERMANENT CLO <br />RE <br />Removal or Permt <br />C:osure in Place <br />TANK ID # (s) : <br />TEMPORARY CLOSURE <br />CLOSURE FEE = $375 / TANK # TANKS X S375 = <br />$ <br />Plan Review and In ections <br />[TANK 10 # (s) : <br />TEMPORARY CLOSURE FEE = $375 / FACILITY <br />$ <br />INSTALLATION PLA14 <br />CHECK <br />{Plan Check and Con iruction Inspections'. <br />TANK ID # (s) : <br />PLAN CHECK FEE _ $1,000 / FACILITY <br />$ <br />REPAIR PLAN CHE <br />TANK ID # (s) : <br />TANK RETROFIT RE >AJR FEE = $375 / FACILITY (use for monitoring equipment, cold starts, EVR ubgrades, <br />S <br />ill buckets, sum s, misc. <br />PIPING REPAIR FEE <br />$375 /FACILITY(use for piping,' under -dispenser containment, ect.) <br />$,j?S.— <br />MISCELLANEOUS <br />TRANSFER FEE <br />$ 25 <br />$ <br />CONSULTATION FEE <br />= S 1251 HOUR <br />$ <br />UNAUTHORIZED REI <br />EASE -EVALUATION FEE = $ 125 /HOUR <br />$ <br />SAMPLING INSPECT <br />N FEE = $ 1251 HOUR <br />$ <br />ALL FEES ARE BASED <br />N THE $125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br />TOTAL AMOUNT <br />DUE <br />OFFICE USE ONLY <br />SERVICE REQUEST # <br />FACILITY ID AMOUNT RECEIVED CHECK # RJ CEIVED BY DATE RECEIVED <br />EH 23 032. (REVISED o81 <br />11 by KF1 <br />