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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> / IF FACILITY/SITE NAME T ��-- FACILITY CONTACT NAME <br /> CII ;Aell o INCZc/G arneas <br /> I <br /> L STREET ADDRESS SITE PHONE 1 NET" AmcA eons <br /> I / 3i3 iG. eAec y g— S' 3is <br /> I <br /> Y CITY STAT ZIP CODE1 of Tanks ` <br /> 5 '-G c% {zJs7 e-4at Site (v <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L 7CD�Pr' .y- L.6-e £i_ Assc. <br /> I MAILING ADDRESS APPLICANT PHONE 1 M2TH •NEA c009 <br /> A 3 3 7 L/ c iP 69riP 1�9/I>� .C> Y(Q! Uv-s <br /> N CITY STAT 21P'COBE TYPE of APPLICATION , ;n <br /> T _— _ CLOOYnr. INET�LL�TION, ETC. P•� 9 <br /> �c' 2„<o �°A 9�3 Bas <br /> FAACQIL(T�Y FEE = 1100.00 each SITE ADDRESS Per YEAR T •�* 1 <br /> EXPLANATION AMOUNT -1271 <br /> ROBERT LEE ASSOCIATES, INC. <br /> 13 r 1322 <br /> L; 1737 NOWE AVE.,SUITE 211 <br /> SACRAMENTO,CA 95825 <br /> 19161 6464003 411-2 19 <br /> AMOUNT PA Y �t XTy� jjjf f �/r'� 1-1 �a S r-1Dollars I AMouNT <br /> OF �cc� <br /> THE <br /> TO <br /> OF DER <br /> SACRAMENTO OFFICE <br /> *k WESTAMERICA BANK 1610 ARDEN WAY <br /> SACRAMENTO,CA 95866 <br /> .._... <br /> l-116Nunnr,r uLuauAt rct = muu.UO each TANY. I 1 Tanks x (80.00 IS <br /> P PLAN CHECK (Installation or Repair) — <br /> 11 PLAN CHECK FEE = $30.00 each SUBMIS5[Ot ESUCMISSION 1 C7 �_ <br /> REPAIR <br /> R TANY, REPAIR FEE _ $110.00 each TANK — ! Tanks x fI10.00 f <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION — <br /> (when applicable) (when applicable) When applicable) <br /> FEE = 130.00/hr $35x00/hr — ^-- FEE =f35,001hr — $ <br /> _^� hr -- <br /> m. 3 S <br /> TOTAL DUE I s o <br /> Off ICE USE ONLY ca <br /> P'.fl!.i�"I�CIC?a"Cll�llllp�!I!19:"!�,mC1iC1!�II@'ICC94fiII�IIP�pCI 'UIlCJ1C!�C!II�C!iiC114W�":�!�iC�iVi19CiV?I'ViIN .":i�'JrC01!99@Mu!lN!II�EVWp'ICAC!iil(uliffi�IClifrl!!GC11iCICIii�41uC91Ul�CiCl?ul fIICCpC1129C1ri�ICiIIICBfi�ICN!I�18h'd"dC!Ci!CCIIdVC6yiVi�'d"u1CGC" <br /> SUEEPS 1 COMP 1 LOC CODE DIST 'aDE AMOUNT DUE AMOUNT RCVDH r /CASP RrVD BY DATE PECEIVED ( PEPMIT I <br /> .:,CCC7!hnll!711';,mll4:IMP'IIhIICIIGIIIP!Mm¶lgi9tlIPII�ItlulllQlmiryTd'I�nCul°Iii ml !i?I11(lm,il �!!!�,�ii! ICI P;; Imll'II ql�.�: <br /> C"CC. PSI 1 �IIII IICICClICC .CLIIJI�CII:DIIIrIIimGlllllil�IIRUT m1oo:Immlmimmmmlm1111Namom�m�ml(oomr.Ialomllaumiailllllmmi..l <br />