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Jun 24 10 02:50p Reliable PetroleumA 209-845-8953 p.6 <br />CAJ C <br />N OAQL'1'V OU`T'I <br />ENviRONMENTAL HEALTH DEPARTMENT <br />600 East Main Street, Stockton, CA 95202-3029 <br />Telephone: (209) 468-3420 Fax: (209) 468-3433 Web: www.sjRov.org/ehd <br />F`A�CIL17Y NAME <br />APPLICANT CONTACT NAME <br />FACILITY CONTACT NAME <br />t'T am Yy\ t Y" 01l— <br />s' -L\ <br />IS LA t' <br />FACILITY ADDRESS <br />I ZIP CODE <br />SITE PHONE # WITH AREA CODE <br />3 o1-\ w. qz"mVAer <br />a !L} <br />CITY <br />STATE <br />ZIP CODE # OF TANKS AT SITE <br />_{ -,� <br />S+d c�� SCJ <br />CA <br /><95-2-o LP III <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />e.-iCt' 0 � f MOA '&,r ✓, (,L/.L� <br />APPLICANT MAILING ADDRESS <br />APPLICANT PHONE #WITH AREA CODE <br />s' -L\ <br />8' Gy <br />C[TY STATE <br />I ZIP CODE <br />CIRCLE WORK TO BE DONE <br />CONTRACTOR ICC # <br />a !L} <br />S73 U ! <br />Closure Installation epair Retrofit <br />k� I <br />..v.,scvr1-14.ee r <br />$500 FEE INCLUDES FACILITY FEE + 1 TANK (2003-2008) <br />$550 FEE INCLUDES FACILITY FEE + 1 TANK (2009) <br />$125 PER TANK AFTER FIRST TANK <br />2004 <br />2005 <br />20()6 <br />2007 <br />20D8 <br />1 2009 <br />$ <br />TANK PENALTY ASSESSED <br />$ <br />TANK SURCHARGE = $15 / TANK <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$24.001 FACILITY <br />$ <br />:PERMANENTCLOSURE <br />Removal or Permitted Closure in Place <br />TANK ID # s CLOSURE FEE= $315 /TANK # TANKS X $315 = <br />TEMPORARY CLOSURE <br />Plan Reaiew and Inspections) <br />TANK ID # (a): TEMPORARY CLOSURE FEE = $3151 FACILITY <br />nj• <br />TANK ID # (s) : PLAN CHECK FEE = $$40 / FACILITY ( T. I <br />IDX <br />TANK RETROFIT REPAIR FEE =S315/FACILITY (use for monitoring equipment, cold starts, EVR upgrades, 2t�5 <br />'II buckets, sum s, misc. J <br />PIPING REPAIR FEE = $3151 FACILITY (use for ob . under-disnomar nnnrarnmo.,r o,.. -i $ <br />