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Jul 25 13 05:22a Reliable Petrolejlm 20OR458953 <br /> p.6 <br /> RECEIVE® <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTAIF_NT JUL 2 5 2013 <br /> 6D0 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)465-3420 Fain(209)468-3433 Web.w%v%%I.sieov-orgh-W ENVIRONMENTAL <br /> FACILITY NAMEI-)EALT N DEPARTMENT <br /> FACILITY CONTACT NgME <br /> �1. I D ADDRESS QS .! <br /> FACILITY SITE PHONECrTy <br /> #IMITH AREA CODE <br /> STATE ZIP CODE <br /> CA ``S� ?OF TANKS AT SITE <br /> I C3� V <br /> APPLICANT BILLING NAME APIPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#IMTH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> • ClCsure Installat* <br /> aii_ Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE JNCLJDES FACILITY FEE+1 TANK(207-2008) 2007 200$ 2009 2010 2011 2012 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008-2012) <br /> $125 PER TANK AFTER FIRST TANK $ <br /> TANK PENALTY ASSESSED $ <br /> TANK SURCHARGE=S15 i TANK S <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON'NVENTORY IN A CUPA PROGRAM=$49.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal er Permitted Cicsure In Place) <br /> TANK ID* s' : CLOSURE FEE=$375)TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Flan Review and Inspections <br /> TANK ID#;s} TEPAPORARY CLOSURE FEE=5375 1 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ectiorns <br /> TANK ID#(s): PLAN CHECK FEE=$1000 1 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK 0#,$): <br /> TANK RETROF.T REPAIR FEE =$3751 FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ <br /> spill buckets,sumps,mist. <br /> PIPING REPAIR FEE =$375 i FACILITY {use for piping under-dispenser containment,ect) $.3 7�I <br /> NRSCELLANEOUS <br /> TRANSFER FEE = S25 $ <br /> CONSULTATION FEE = $'25.1 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $125/HOUR $ <br /> SAMPLING WSPECTION FEE = $125,`HOUR $ <br /> A�.L FEES ARE BASED ON THE$125 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE <br /> OFFICE USE ONLY <br /> SERUlCE REQUEST# FACILITY ID AMOUNT RECEIVED_ CHECK# RECEIVED BY DATE RECEIVED <br /> EH 23 032[REVISED 04/13/12 by KF] <br />