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Aug 12 09 11:21a Reliable PetroleumA 209-845-8953 P.9 <br /> SAN JOAOIJIN COUN Y <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Stmt,Stockton,CA 95202-3029 <br /> Tekpkarse:(209)468-3420 Fax:(209)468-3433 Web.w%vw.siao`r.mlehd <br /> FACILITY NAME �+ FACILITY CONTACT NAME <br /> t 1<K�aG�I G a 5 /V1 CG`� 04,-i&L Tj W&A-a <br /> FACILITY ADDRESS SITE PHONE#I ITH AREA CODE <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> stw-m\ CA �5ad <br /> APPLICANT BILLING NAME �* APPLICANT CONTACT NAME <br /> KI✓iltWie- )`�1 l fJf1�6iVV JL`'V4�i LAS Lr1C. ltO�jL'(�� rY,,k(- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CI'T'Y FSTATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> (i EL Il,0..�. . r �� Closure Installation Repal RetmflI S7a Sr?S-�Q <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(200:1-2008) 2004 2005 2006 1 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(200:; <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=$151 TANK $ <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$24.001 FACILITY $ <br /> PERMANENT CLOSURE <br /> emmal or Permitted Closure in PNace <br /> TANK tD#W: CLOSURE FEE=$3151 TANK P TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> I (Plan ReAew and Irmpecti22sj <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$395/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction E ions <br /> TANK 10#(s): PLAN CHECK FEE_$8401 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(a): <br /> $ <br /> TANK RETROFIT REPAIR FEE =$3151 FACILITY (use for monitoring equipment,cold starts.EVR upgrades, <br /> ill buckets s ,misc. <br /> PIPING REPAIR FEE =$3151 FACILITY use for pleing.under-dispemercontainaent,ect.) <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1051 HOUR $ <br /> SAMPLING INSPECTION FEE = S 1051 HOUR $ <br /> ALL FEES ARE BASED ON THE$100 HOURLY RATE. TIS TMAT EXGEED$FEES PAID VALL BE BELLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# RECEMED BY DATE RECEIVED <br /> SR <br /> EH 23 032(RISASED 6023/it9) 1 m , i I-- <br />