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Jun 24 10 b9:54a Reliable PetroleumaA <br />2 -845-8953 p.6 <br />SAN JOAQUIN COUNTY <br />ENVIRONMENTAL, HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax. (209) 468-3433 Web: ww-v.sjgov.org/ehd <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />Ca )AV S �PC,)--F <br /><C'j ; �, t� u ✓^ <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />Ib3 D a 4 0 5t -OA ` -Av -,f- vl "-P- <br />.90 y e a s- 0 3 3 2 - <br />CITY STATE <br />ZIP CODE # OF TANKS AT SITE <br />A A -h --- - Cry <br />01 5 3 3 (o -3 <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />ReA*40-c Pe AA (o l r v,,, S f v;c.�S r c.. <br />Robert-�-�-- <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE # WITH AREA CODE <br />S �a- 6y-o.y�d.4 <br />CITY <br />STATE ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />00. }G�a.i-� <br /><' f S3 (� 1 <br />Closure Installation �r Retrofit <br />AL r IV C FACILITY <br />TANK ID # s : CLOSURE FEE= $3451TANK #TANKS X $345 = <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2004-2007) <br />$550 FEE: INCLUDES FACILITY FEE + 1 TANK (2003-2010) <br />$125 PER TANK AFTER FIRST TANK <br />2005 2006 <br />2007 <br />2008 <br />2009 <br />2010 <br />SAMPLING INSPECTION FEE = S 1151 HOUR <br />ALL FEES ARE BASED ON THE 3116 HOURLY RA7F TIRM TWA =Vf•=Cnc ecce• <br />$ <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $151 TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A COPA PROGRAM =$49.001 FACILITY <br />$ <br />PERMAN T CLOSURE <br />Removal or Permitted Closure in Places <br />TANK ID # s : CLOSURE FEE= $3451TANK #TANKS X $345 = <br />TEMPORARY CLOSURE <br />Plan Review and Inspections) <br />TANK ID # (s) : <br />TEMPORARY CLOSURE FEE = $3451 FACILITY <br />ION PLAN CHECK <br />and Construction Ir <br />TANK ID # <br />PLAN CHECK FEE = $920 / FACILITY <br />REPAIR PLAN CHECK <br />TANK ID # (s) : <br />TANK RETROFIT REPAIR FEE = $345 / FACILITYuse for monitoring <br />( g equipment, cold starts, EVR upgrades, <br />spill buckets, sumps. misc.)�,/g <br />$ <br />PIPING REPAIR FEE =$345/FACILITY( use for ' 'n ,under -di ensercontainment,ect.) <br />$-3/.,sr,'R <br />MISCELLANEOUS <br />TRANSFER FEE _ $ 20 <br />$ <br />CONSULTATION FEE _ $ 115/HOUR <br />$ <br />UNAUTHORIZED RELEASE EVALUATION FEE = 3 115 / HOUR <br />$ <br />SAMPLING INSPECTION FEE = S 1151 HOUR <br />ALL FEES ARE BASED ON THE 3116 HOURLY RA7F TIRM TWA =Vf•=Cnc ecce• <br />$ <br />OFFICE USE ONLY <br />