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Aug 13 12 12:26p Reliable PetroleumA 209-845-8953 p.6 <br /> 40 <br /> SAN JOAQUIN COUNTAI <br /> ENVIRONME\7AL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> TehThone. (209)468-3420 F=(209)469-3433 Web;www.sigoy.orgiebd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRE)S SITE PHONE 0 WITH AREA CODE <br /> I CITY STATE zi CODE 9 OF TANKS AT SITE <br /> CA <br /> J... . <br /> APPLICANT BILL NG NAME APPLICANT CONTACT NAME <br /> (OdU Part)L-P s-vl <; <br /> �- <br /> APPIUCANT MAIL ING ADDRESS APPLICANT PHOINE#VOTH AREA kAjL)E <br /> 1�Cfbo A0Aj ( ;'Of) <br /> CITY STA—TE ZIP CODE CIRCLE WORK TO BE DONE comm=rOR ICC'* <br /> CAV y -- 0145-1. <br /> Closure InstaWIbn;We`pa'1?), Re C:9 95 <br /> ACTIVE FACILITY <br /> 2007 2008 2009 2010 2011 2017 <br /> $500 FEE INCLUE ES FACILITY FEE+1 TANK(2007-2008) <br /> $550 FEE INCLUE Es FACILITY FEE+1 TANK{2009-20121 <br /> $125 PER TAW fl-TER FIRST TAW <br /> TANK PENALTY A 3SESSED <br /> TANKSURCHAR: E=$151TANK <br /> STATE SURCH E FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.00/FACILITY <br /> PERMANENT CIL SURE <br /> ( <br /> Perri Removal or Pe Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$376/TANK #TANKS X$375= <br /> TEMPORARY CL(ISURE <br /> (Plan Review and I ispecAlorr.) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE=$375 1 FACILITY <br /> INSTALLATION MAN CHECK <br /> (Plan Check and C wistruction Inspections) <br /> TANK I D*(s): PLAN CHECK FEE=$10001 FACILITY <br /> REPAIR PLAN Cl-ECK <br /> TANK ID#(s): <br /> TANK RETROFIT I ZEPAIR FEE =$375 J FACILITY (use for monitoring equipment,cold starts,EVIR upgrades, <br /> spill buckets,sumps,misc.) <br /> PIPING REPAIR FEE =$375fFACILITY use for p1ping,under-dispenser containment,act.) <br /> MISCELLANEOUI <br /> TRANSFER FEE $25 $ <br /> CONSULTATION I EE = S 1251 HOUR $ <br /> UNAUTHORIZED LEASE EVALUATION FEE = $125 1 HOUR $ <br /> 51 <br /> 1 —t$— <br /> SAMPLING INS TION FEE A HOUR <br /> BAS <br /> [) <br /> ALL FEES ARE 0 ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> C)tj I <br /> TOTAL AMOU T DUE $ <br /> OFFICE USE ONI. <br /> SERVICER UEST 9 FACIUTY 10 NT RECEIVED CHECKi RECEIVED BY I DATE RECENED <br /> EH 23 032(REVISE 10 04113112 by KF) <br />