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Jun 23 14 04:35a ReliablePetrolQum 2nQ8458953 p.22 <br /> SAN JOAQUIN COUNTY <br /> EN'rRONNffiNTAL HEALTI4 DEPARTMENT � x <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(204)468-3433 Web:www siov or�!ehd JUN 2 2014 <br /> FACILITY NAME <br /> FACILITY CONTACT NAME <br /> Q-- also �� Jest jNVIR L.TH <br /> FACILITY ADDRESS EA <br /> Oct I <br /> CIT <br /> IF STATE <br /> CA ZIP CODE A OF TANKSAT SITE <br /> APPLICANT BILLING NAME APPLICANT CONTACT NA1NE <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STA E Z CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure Installation Re air Retrofi' <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+I TANK(2007-2008) 2007 2008 2009 2010 2011 2012 <br /> 5550 FEE INCLUDES FACILI'Y FEE+1 TANK(2„09-2072) <br /> S125 PER'ANK AFTEER FIRST TANK $ i <br /> TANK PENAL.YASSESSED $ <br /> TANK SURCHARGE=$15/TA $ <br /> NK <br /> STATE SURCHARGE FOR FACILITIES NOT ALREADY ON 114VENTCRY INA CUPA PROGRAM=S49.00/FACILITY W <br /> PERMANENT CLOSURE <br /> (Removal or Permitted Closure in Place <br /> TANK ID# s : CLOSURE FEE-S375 TANK #TANKS X S375= $ <br /> TEMPORARY CLOSURE <br /> Plan Review and Ins ections' <br /> TANK J A(s) TEMFCRARY CLOSURE FEE=$375/FACILITY $ <br /> INSTALLATIONPLAN CHECK <br /> Flan.Check and Construfton Ins etions <br /> TANK ID A(s): PLAN CHECK FEE=$100D 1 FAC1LfTY $ <br /> REPAIR PLAN CHECK <br /> TANK 17*(s): <br /> TANK RETROFIT REPAIR FEE =$375;FACILITYuse for monitoring $ <br /> ( ng equipment,cold starts,EVR upgrades, <br /> s ill buckets,sum s,misc.I, <br /> PIPING REPAIR SEE =S375/FACILITY (use`er piping.under-dispenser containment.ed.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $1251 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $125 1 HOUR $ <br /> SAMPLING INSPECTION FEE S 1251 HOUR $ <br /> ALL FEES ARE BASED ON THE 5725 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> TOTAL AMOUNT DUE $3c) <br /> OFFICE USE ONLY <br /> SERWICE REQUEST V FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIV_D <br /> EH 23 032(REVISED 04/13112 by KF) <br />