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Jan 14 11 09:57a Reliable Petroleu 20 45-8953 p.6 <br /> SAN JOAQUI N COLWrY <br /> ENVIRONMENTAL HEALTH DEPARTMENT <br /> 600 East Main Street,Stockton,CA 95202-3024 <br /> Telephone:(209)46$-3420 Far:(209)468-3433 Web:,,vww.sj&E.orlrlehd <br /> FACILITY NAME I FACILITY CONTACT NAME <br /> Ag <br /> CC ri t 6tit �a l p 6 2 P..aV\ <br /> FACILITY Abp SS SITE PHONE#WITH AREA CODE <br /> Cq`13b jot. Po 'bo ea.r>Lw -- 33 a- 'M <br /> CITY I STATE ZIP COM #OF TANKS AT SITE <br /> -Ifo- I CA !S 3 <br /> I <br /> APPLICANT BILL ING NAME APPLICANT CONTACT NAM <br /> e Iia bt ! �e rc� E e&1a� S�t-vrco ( (��rt- 6a oi <br /> APPLICANT MAII JNG ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> ncno <br /> CITY STATE. ZIP CODE CIRCLE WORK TO BE DONE CONTRACTOR dCC# <br /> 0, C-0. Q`j �j(�► Closese Instailati Repair ReiroCct �l�sa if(1 <br /> I <br /> ACME FACT <br /> 2005 2006 2007 2008 2009 2010 <br /> $500 FEE INCLU S FACILITY FEE+I TANK(2005-2007) <br /> $550 FEE INCLU S FACILITY FEE+I TANK(2008-201o) <br /> $125 PER TANK ER FIRST TANK $ <br /> TANK PENALTY A I3SESSED $ <br /> TANK SURCH E=$1 s t TANK $ <br /> R <br /> STATE SURCHAR E FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRALf=$4.9.00/FACILITY $ <br /> PERMANENT CLC SURE <br /> 22MOval or Perm ted Closure in P4ace <br /> TANK ID# s : I CLOSURE FEE=$3661 TANK #TANKS X$366= $ <br /> TEMPORARY CLC SURE <br /> Plan Rev*w and t cam <br /> TANK 10#(S): TEMPORARY CLOSURE FEE=$366 f FACfLIlY $ <br /> I <br /> INSTALLATION Pt ARN CHECK <br /> Plan Check and Cc 11sInsdon Ins ons <br /> I <br /> TANK ID#(s): PLAN CHECK FEE_$976 f FACT{17Y ' <br /> REPAIR PLAN CH K <br /> TANK ID#(s): <br /> TANK RETROFIT R EPAIR FEE _$366/FACILITY (use far r 0ft)Mg WjOmnt cold starts,EVR u $ <br /> If buckets,su mise ' <br /> PIPING REPAIR FE _$366 f FACILITY use for ,=Jw-dspensw contsjmnent,eq $ !{? <br /> WSCELLANEOUS . <br /> TRANSFER FEE _ $25 $ <br /> CONSULTATION FEE = $122f HOUR $ <br /> UNAUTHORIZED RI 1EASE EVALUATION FEE = $1221 HOUR $ <br /> SAMPLING INSPE ION FEE _ $122/IiOUR $ <br /> ALL FEES ARE BASF--lOAI Tw$I=FjoHtLy RATE. 17LL'TMAT FXCEE03 FM PM Will 13E MLLED TO <br /> APPLMAW- <br /> OFFICE USE ONL <br /> SERVCE REQUEST# I F ID AMOUNT CHECK# BY DATE RECEIVED <br /> SR <br /> EH 23 032(REVMM 9,'�I11Q) <br />