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Mar 31 09 02:08p Reliable PetroleumA 209-845-8953 p.9 <br /> 'SAN J0;i0UIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fax:(209)468-3433 Web: www•sigov.or;/ehd <br /> FACILITY NAME <br /> FACILITY CONTACT AME <br /> J�a7 n Strt�t ,4 i2-CD j e ss e G 'LCA <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITYTV aU ^I-) s la 7 y <br /> STATE ZIP CODE <br /> Ma-y0. #OF TANKS AT SITE <br /> q�3� � � <br /> APPLICANT BCA BILLING NAME APPLICANT CONTACT NAME <br /> ttQ�Ie �ef1r� ISe v�Lfs'� <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> Sar 81�a►1c�i+ T r�� s �aq �0 ;- 933 C� <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Closure lnstaflatio Repair�Retrofitr�s0 1I ` <br /> S/ -l{ � <br /> ACTIVE FACILITY <br /> 5500 FEE INCLUDES FACILITY FEE+1 TANK(2003-2008) 2004 2005 206 2007 2008 2009 <br /> $550 FEE INCLUDES FACILITY FEE+? TANK(t10`.: <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 /> Removal or Permitted Crosure in Place <br /> TANK fD# s : CLOSURE FEE_$315/TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s) : TEMPORARY CLOSURE FEE _$315/FACILITY $ <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction Ins ections) <br /> TANK ID#(s): PLAN CHECK FEE=,$8401 FACILITY $ <br /> REPAIR PLAN CHECK <br /> TAN K I D#(s): 3 <br /> TANK RETROFIT REPAIR FEE _$315/FACILITY (use for monitoring equipment.oold starts,EVR upgrades, $2 0� <br /> s ill buckets,-surnps,misc.) J�� <br /> PIPING REPAIR FEE =$315 l FACILITY use for pi in ander-dis enser containment,ect. $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $ 105/HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $ 105/HOUR $ <br /> SAMPLING INSPECTION FEE _ $105!HOUR $ <br /> ALL FEES ARE BASED ON THE$105140URLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BLLED TO ApPLICANT- <br /> OFFICE USE ONLY <br /> LSERCE REQUEST# FACILITY FD AMSOUNT RECEIVED CHECK# RECEIVlcp BY DATE RECEIVED <br /> L <br /> EN 23 032(REVISED 02123109) <br />