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SAN JOAQUIN LOCAL HEALTH DIG-TRICT <br /> �„jERGROUND STORAGE TANK PROGRAM - FEE AORKSHEa., <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A ' <br /> I Ara 4 /JS �vC R C,r UlkersorJ <br /> L STREET ADDRESS SITE PHONE 1 (with Area Code) <br /> T 3133 4�'Arf <br /> Y CITY STATE LIP CODE 1 of TANK'S <br /> o C'A 9 s at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P -FJr� it vs %C <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C 133 /J. Ad-�Q'rf 00W <br /> A 209 � �i -asdo <br /> N CITY STATE LIP CODE TYPE of APPLICATION $o;J <br /> T S�or 4rrJ �� 2OS-- (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 I'388 1989 <br /> T <br /> I <br /> V $ <br /> c Tawv rFF == $50.00 each TANK <br />[PAY <br /> BRT SIGNS, INC. PACIFIC STATE BANK <br /> 20T EAST MAIN STREET <br /> DATEAMOUNT 7-13-89 21635 <br /> rt $35 .00 <br /> y five dollars and no/100----____------- NOT VALID AFTER 180 DAYS <br /> A <br /> nty of San Joaquin <br /> • <br /> REPAIR <br /> --- <br /> E TANK REPAIR FEE = $110.00 each TANK 1 Tanks x $110.00 $ <br /> P <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, Ainisus one hour to he paid on plan sub®ittal) <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLINGr(�� <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 530.00/hr FEE = $35.00/hr IFEC = $35.00/hr �_ $ 5 Ow <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> . . 1w1." a AN•} <br /> SWEEPS t COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCV CHECK ASH RCVD BY GATE RECEIVED PERMIT 1 <br /> ori F 3 y 35°° 3S� #�J6j c -- --- <br /> 7/rs/� � <br />