Laserfiche WebLink
Sep 03 09 04V p Reliable PetroleumA 209-845-8953 p.9 <br /> 0 0 <br /> SAN JOAQUIN COUN-W <br /> EwRo AL NF..ALTH DEPARTAr1ENI' <br /> 600 East Main Street,Stockton,CA 95202-3029 <br /> Telephone:(209)468-3420 Fru:(209)468-3433 Web:v%,%v`v sjgov_or9/ehd <br /> FACILITY NAME FACILrrV CONTACT NA4p11S <br /> t OlAb'l�Y 419d A/ I�i.C..e,Q. ��til L. Lid e-.r^ <br /> FACILITY AD REBS SITE PHONE#WITH AREA CODE <br /> ISS C`o��1t CI. bloc aaq <br /> CITY I STATE ZIP CODE #OF TANKS AT SITE <br /> >r L Ci rrl CA52— <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> f-LA`'�t S-f-rVi L e s kobef+ rEJLO-t--4 <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> 2.t g u r1�%r� �U`� a a�v/ rv!s-- g s�y <br /> CITY STA1tTE21P CODE CIRCLE WORK TO BE DONE CONTRACTOR ICC# <br /> 9'53(P1 Closure Installation Repair Retrofit SZC- 51-u I <br /> ACTIVE FACILITY <br /> 20041 2005 2006 2007 2008 2009 <br /> S5D0 FEE INCLUDES FACILITY FEE+1 TANK(2004-2007) <br /> 5550 FEE INCLUDES FACILITY FEE 4-1 TANK <br /> 3125 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 COPA PROGRAM[=S49.001 FACILITY $ <br /> PERNANENTCLOSURE <br /> Removal or Permitted Clasurs in Place <br /> TANK ID# s : CLOSURE FEE=$3451 TANK #TANKS X$345= $ <br /> TEMPORARY CLOSURE <br /> Plan Reuiew axed inspections <br /> TANK ID# s): $ <br /> ( TEMPORARY CLOSURE FEE_$345/FACILITY <br /> INSTALLATION PLAN CHECK <br /> Plan Check and Construction I ons <br /> TANK ID#(s): PLAN CHECK FEE_$920/FACILITY <br /> REPAIR PLAN CHECK <br /> TANK ID#(s): <br /> TANK RETROFIT REPAIR FEE =$345 1 FACILITY (use for nwnitoNn $ <br /> g equipn�M,cold starts,EVR upgrades, <br /> spill buckets,sumps.mise. <br /> PIPING REPAIR FEE _$8451 FACILITY use for ,under-dispenser containment,e#. <br /> _ 60 <br /> MISCELLANEOUS <br /> TRANSFER FEE _ $20 $ <br /> CONSULTATION FEE = $1151 HOUR $ <br /> UNAUTHORIZED RELEASE EVALUATION FEE _ $1151 HOUR $ <br /> SAMPLING INSPECTION FEE = $1151 HOUR $ <br /> ALL FEES ARE BASED ON THE S11 S HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLM TO A"LICMM <br /> OFFICE USE ONLY <br /> SERVICEREQUEST# WMJTYID AMOUNT RECEIVED CHECK# RECEIVED BY DATE RECEIVED <br /> SR <br /> EN 23 032(REVISED 07101109) <br />