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Jan 24 11 09:11 a Reliable PetroleumA 209-845-8953 p.6 <br /> SAN JOAQUIN COUN'T'Y <br /> ENVIRoNmENTAL HEALTH DEPARTMENT <br /> 600 East Main Sweet, Stockton,CA 95202-3029 <br /> Te/epkome.(209)468-3420 Fmr:(209)468-3433 Web:www.siaov.ozgehd <br /> FAmCILITY NAME FACILITY CONTACT NAME <br /> FACILITY ADD S SITE PHONE#WITH AREA CODE <br /> IGD S /til �v. Sine q ��5_(s,7� � <br /> CITY STATE DP CODE #OF TANKS AT SITE <br /> rnG�vt-4e c CA ` 533 Lp <br /> APPLICANT BILL NG NAME APPLICANT CONTACT NAME <br /> �f- <br /> APPLICANT MAILING ADDRESS APPLICAKT PHONE#WITH AREA CODE <br /> (1 q 3 D <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> Q C 5 ?J(�, closure Installat;o Repai�'Retrofit 152,5257 vo <br /> ACTIVE FACILITY <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLUE ES FACILITY FEE+1 TANK(2005-2007) <br /> $550 FEE INCLUE ES FACILITY FEE+1 TANK(2008-2010) $ <br /> $125 PER TANK AFTER FIRST TANK <br /> TANK PENALTY P SSESSED <br /> TANK SURCHAR E=$15/TANK <br /> STATE SURCHAR 3E FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM=$49.001 FACILITY <br /> PERMANENT CLC SURE <br /> Removal or Peffn led Closure in PFaoe <br /> TANK ID# s CLOSURE FEE=$3661 TANK #TANKS X 5366= <br /> TEMPORARY CL URE <br /> Plan Review and sections <br /> TANK ID#(s): I TEMPORARY CLOSURE FEE_$366/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Cxistruction I lions) <br /> $ <br /> TANK 10#(s): PLAN CHECK FEE_$976!FACILITY <br /> REPAIR PLAN C ECK <br /> TANK ID#(s): r <br /> TANK RETROFIT IEPAIR FEE =$366/FACILITY (use for monitoring equipment,cold starts,EVR upgrades, $ 1) <br /> spill 5uckets,sumps,mise)✓`�w' <br /> $ <br /> PIPING REPAIR FEE _$366/FACIUTY (use for piping,under-dispenser containment,ect. <br /> PAISCELLANE01.18. <br /> TRANSFER FEE _ $25 <br /> CONSULTATION EE _ $1221 HOUR <br /> UNAUTHORIZED ELF-ASE EVALUATION FEE _ $1221 HOUR <br /> $AMPLINC 1NCP.. TION EFF_ _ $1221 HOUR <br /> ALL FEES ARE BASED ON THE$122 HOLIRLY RATE TINE THAT EXCEEDS FEES PAID WILL BE BULLED TO APPLICANT. <br /> OFFICE USE O LY <br /> SERVICE REQUEST V FACILITY ID AMOUNT RECEIVED CHECK# I RECENED BY I DATE RECEIVED <br /> SR <br /> EH 23 032(REVISEC 07121110) <br />