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Jul 25 13 05:28a Reliable Petrol- � 21 458953 p.22 <br /> SAN JOAQUIN COUNTY RECEIVED <br /> ENVIRONMENTAL HEALTH DEPARTMENT JUL <br /> 600 East Main Street,Stockton,CA 95202-3029 2 5 20�3 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web:www-sjgov.orR&h1A 11, <br /> FACILITY NAME U�d jp <br /> - TAL <br /> FACILITY CONTACT NAME AL <br /> 1k'IlI o ^NT <br /> FACILITY ADDRESS SITE PHONE#WTH AREA CODE <br /> S Lf y..o (-„ 1`�M I. S��'�e 0 y L,4,3--7 11�p <br /> CITY STATE <br /> ZIP CODE A OF TANKS AT SITE <br /> CA 1570 <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> 41A1,PPLICAINITI MAILING ADDRESSAPPL)CANT PHONE#WITH AREACODE <br /> nn ^ I q z;l <br /> O� <br /> STATE ZIP CODE CIRCLE WORK TO BE DONECONTRACTOR ICC# <br /> Cfosure Instaffation RVOaiii Retrofit _ 7 <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2007-2008) 2007 2008 2009 2010 2011 2012 <br /> S550 FEE INCLUDES FACILITY FEE 1 TANK(2009-20121 <br /> S125 PEP.TANK AFTER FIRST TANK <br /> TANK PENALTYASSESSED <br /> TANK SURCHARGE=$15/TANK F7 <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=S49.00/FACILITY <br /> PERMANENT CLOSURE <br /> Removal or Permuted Closure in Place) <br /> TANK ID#(s): CLOSURE FEE=$375/TANK #TANKS X$375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections <br /> TANK 1D#(s). TEMPORARY CLOSURE=EE_$375.1 FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> P an Check and Ccnstruaion Inspections) <br /> TANK 1D#(s) PLAN CHECK FEE_$1000;FAC ILfTY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s)- <br /> TANK RETROFIT REPAIR FEE =$375 i FACILITY (use for monitoring equipment,cold starts,EVR upgrades, <br /> spit: buckets sumps,mist.) <br /> PIPING REPAIR FEE =S375/FACIJ Y (use for oiping,under-dispenser containment em) $37 a, <br /> MI <br /> SCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE _ $1251 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $125/HOUR $ <br /> SAMPLING INSPECTION FEE _ $1251 HOUR $ <br /> ALL FEESARE BASED ON THE$125 HOURLY RATE. TIVE THAT EXCEEDS FEES PgID WILL 6E BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE — <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID I AMOUNT RECEIVED CHECK# �_ RECEIVED 8Y DATE RECEIVED <br /> EH 23 032(REVISED 04/13112 by KF) <br />