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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE RORKSHEET �� f' <br /> FACILITY/SITE NAME FACILItY CONTACT NAME <br /> A <br /> CSOL 11a <br /> STREET ADDRESS c ^ (�„ „ . � SIT PHONE 1 NItN AAAA COCl <br /> Y CI;153 <br /> Y ,� „ SAE IIP COD 1 0l iank5 <br /> f _ � at SitelUlf <br /> A APiCANf/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> f PZ8Db M n d6,5k- <br /> 1 MAIL <br /> MGGjAOOPESS ` APPLICANT P NE I Yr}N AAAA too <br /> r.N CITT1 iE�IIP COD APPLICATION <br /> .. �,. <br /> 1829 <br /> K IES <br /> TING <br /> eoANtINCi <br /> stocH7oNr`t?n'.es218 <br /> 28 - .fir p0 9AOYnxit <br /> PAY <br /> � - <br /> LYNte xAxoA' <br /> a�! tti1"43. 0701.CIC101rto b90 2I311• <br /> ',. r"�«.*-:'�f'a'.t: :l°"tt�i "�''�..�"' � _Y""�.•. J 1 tanks.,.t�7__ t 130.00 � t 7JC /. <br /> iaw� A <br /> 7 TEMPORARY CLOSURE (Only a�ltovfl(400 114e for up to No years) _ <br /> E TEMPORARY CLOSURE FEE If ,.180.00 oath TANK � 1 Tanks x 180.00 f� <br /> P PLAN CHECK '(Installation or Repltr) ' <br /> A PLAN CHECK PEE 1 130.00 114th 50011I9SIONIRESU 1 5 OHIlya <br /> or <br /> — 1 <br /> REPAIR --r ED �— <br /> P tANy, REPAIR FEE = 1110.00 oath TANK"I►IAY z O_Lq1 Tanks.,,,_„ x 1110.00 1 <br /> P --- <br /> A PIPING REPAIRICLOSUPElPEMCVAL (Fee1'irepe GA1Q4{A to be paid on plan subAittaU <br /> R UNAUTHORIZED RELEASE EVALUATION CONStUCTI 1ES SAMPLING INSPECTION <br /> When applicable) (when appiI I e) (vhen applicable) — <br /> FEE 2 130.00/hr� FEE_1D;.00/hrI `— — FEE = 175.00/MI <br /> TOTAL DUE t <br /> DUN( Ott Billy <br /> FSV�EEPS COMP I LOC'COOE B1ef COOS AMOUNT fit AMOUNT RCVD CN1*711/CAoN RCVD OY DATE RECEIVED PEPMIT 1 <br /> D. �...: . .. as. .; ,. .. .. <br />