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Sep 16 08 02:19p Reliable Petroleum 209-845-8953 p.8 <br /> SAN JOAQUIN COUNTY <br /> ENVIRONMENTAL HEALTH DEP�wTrviENT <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fmv. (209)468-3433 Web:www.sif ov.org/ehd <br /> FACILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADDRESS ( SITE <br /> ,�PHONE <br /> ##WITH AREACODE <br /> 1 y 1 0 o 5, F"h��c-'1 I'1 Y �! (06' 0 a �& /F V <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> M6- F �o� -1 CA 953 3 (x) <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> �- <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 11 - <br /> CITY STATE I ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> �c�Kc�CLI - :0:4 <br /> A- 9 53& 1 Closure Installation Repair Retrofit 15d 17-- 7 <br /> ACTIVE FACILITY <br /> $500 FEE INCLUDES FACILITY FEE+1 TANK(2002-2007) 2003 2004 2005 1 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 X24.00/FACILITY $ <br /> PERMANENT CLOSURE <br /> Removal or Permitted Closure in Place <br /> TANK ED# s CLOSURE FEE_$3151 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 /> iPlan Check and Construction Ins eclicns <br /> TANK ID#(s): PLAN CHECK FEE_$8401 FACILITY $ <br /> REPAIR PLAN CHI=CK <br /> TANK ID#(s) <br /> TANK RETROFIT REPAIR FEE =$315/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, �I <br /> spill buckets,sumps, misc. <br /> PIPING REPAIR FEE _$315(FACILITY (use for piping,under-dispenser containment,ect.) $ <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $1051 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE = $1051 HOUR $ <br /> SAMPLING INSPECTION FEE = S1051 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 /> SERVICE REQUEST f# FACILITY ID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVISED 7118108) <br />