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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES �..r <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> F <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> 11 <br /> A <br /> C cJICA VIJN .Je . <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 1 4 o -2q <br /> T CITY STATE ZIP CODE 0 1 # of TANKS <br /> Y7fy at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> SIA <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CCOE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> S <br /> PEHWY. PLACE 4794 <br /> 9355 W. HWY. 4 209-482-2978 <br /> STOCKTON, CA 95206 <br /> i PAY - _ 7_ �J 19 <br /> - TO THE <br /> ORDER OF <br /> N� $ <br /> •i /,�2rr �+lrNf�b�U �'�Bi441 �-�it� / _� <br /> DOLLARS <br /> BankSrockton <br /> jMMu ,3u 1.M !Mlmr Am ,U HIDt <br /> FOR1"IL- <br /> P PLAN CHECK (Install. Plan Review 8 Construction Inspections) TANK I.D. #(s) <br /> L <br /> A <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = 5424.00 mini mm S <br /> R REPAIR FEE (workplan review 8 construction inspections) TANK I-D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X 5159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR FEE = 553.00 per hour (3 hour minimum per facility = 5159.00) $ <br /> N CONSULTATIONSUNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> S <br /> C I FEE = 553.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE S 3 00 <br /> OFFICE USE ONLY <br /> ................................................................................................................................................................................................................................................................ <br /> mua>: sxr OP ' L � L �xacrasSE�c lra <br /> = 2455 ._R3 _. .......... 3z1........... $ 8 .._.... ....!. ..... .. ». K. ......... I-z9-X11......... <br /> :.....31-1..� . ..., . ......_ ........... ................. <br /> EH 23 032 (REV 1/10/911 ft Paae 11 <br />