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Jan 08 Q9 12:42p Reliable Petroleum 209-845-8953 p,8 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street, Stockton, CA 95202-3029 <br /> Telephone:(209)468-3420 FiL (209)468-3433 Web:tvnvw.sjgov.orglehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> AunFACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> CITY STATE I ZIP CODE I #OF TANKS AT SITE <br /> CA 1 9.S--3 Cr <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> able cfy�1 rqffl S(wi yes -:141C. �'���� er4 �A rn 1-)a rj- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> �19) 033 <br /> CITY STATZIP ODE f CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> GQr a-Ve CA Closure Installation Repair Retrofit <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) -2-(-)-03 2004 2005 2006 2007 2008 <br /> $550 FEE INCLUDES FACILITY FEE+1 TANK(2008) <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 Closure in Place <br /> TANK ID#is): CLOSURE FEE= $315 1 TANK #TANKS X$315= $ <br /> TEMPORARY CLOSURE <br /> (Plan Review and Inspections) <br /> TANK ID#(s): TEMPORARY CLOSURE FEE_$3151 FACILITY 71 <br /> INSTALLATION PLAN CHECK <br /> (Plan Check and Construction Inspections) <br /> TANK ID#(s): PLAN CHECK FEE_$840 J FACILITY $ <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$315/ FACILITY (use for monitoring equipment, cold starts,EVR upgrades, $ II <br /> s ill buckets,sum s,mise. -3 l s <br /> PIPING REPAIR FEE _$315 1 FACILITY (use for piping.under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE = S20 S <br /> CONSULTATION FEE = $105!HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $ 1051 HOUR $ <br /> SAMPLING INSPECTION FEE = $ 1051 HOUR $ <br /> ALL FEES ARE BASED ON THE$98 HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APPLICANT. <br /> OFFICE USE ONLY <br /> E REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK* RECEIVED BY I DATE RECEIVED <br /> rSR=L <br /> EH 23 032(REVISED 7118108) <br />