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I <br />SAN JcrAQUIN LOCAL HEALTH DIS....fICT <br />UNDERGROUND STORAGE TANK PR06RAM - FEE WORKSHEET <br />�F FACILITY/SITE NAME <br />c BREr A6t?tctm- 64(- <br />667evIce /,1e <br />L...... <br />FACILITY CONTACT NAME <br />Al),er A/ )il f# <br />A <br />N <br />a0 <br />AN CHECK FEE = $30.0 ach SUBMISSIONIRESUBMISSION 1 <br />1 <br />L STREET ADDR SS <br />alzoa�WA <br />T <br />---- <br />SjTTE_PH E t WITH AREA CGDE <br />�og <br />_� _� <br />Y CITY <br />STMK-rpl�y <br />STAT <br />c? <br />IIP CODE <br />2p5 <br />I 1 of Tanks <br />at Site —_ <br />_ — <br />A APPLICANT/BILLING NAME <br />_(!� <br />APPLICANT CONTACT NAME <br />P 810 AC21QWcrvRAf- <br />u SFi� W lk)e- <br />llo�r &6A <br />L <br />, <br />I MAILING ADDRES <br />AP LICAN PHONE I SITE AREA CODE <br />CDX 101053 <br />209 4�b 5411 <br />A—PL—___ <br />N CITY <br />STAT <br />_ _ <br />zip 'CODE TYPE of APPLICATION RE-EX�Ug7� <br />ETC. <br />CLOSURE. INSTALLATION, O <br />I.IFACILITY FEE = $100.00 each SITE ADDRESS per YEAR I TOTAL <br />-- ............. ...... ........�._._.... ..........-..1 __....._- -r'--- --..._ ... .._.._ . --------- <br />BANK OF AMERICA11- <br /> <br />P. 0. Box 201059 025912 <br />STOCKTON, CALIFORNIA 95201 <br />(209) 466-5911 <br />oATE February 16, 1990 <br />PAY i i1 I r, Ipn l� �mE� $ **65.00** <br />n -1r> mn �nr� -- <br />TO THE ORDER OF <br />'San Joaquin County <br />'Public Health Services <br />VOID AFTER SIX MONTHS FROM ABOVE DATE <br />BREA AGRICULTURAL SERVICE, INC. <br />r <br />P <br />............. ----------- <br />PLAN CHECK (Installation or Repair) <br />L...... <br />A <br />N <br />a0 <br />AN CHECK FEE = $30.0 ach SUBMISSIONIRESUBMISSION 1 <br />TANK REPAIR FEE = 1110.00 each TANK <br />1 Tanksz 1110.00 11 <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br />I-------- —_—� — —� — <br />R UNAUTHORIZED RELEASE EVALUATIONCONSTRUCTION INSPECTION SAMPLING INSPECTION <br />(when applicable) (when applicable) le) <br />FEE = 130.00/hrl — FEE = 135.00/hrl — ^ — FEE = 135.00/hr 1 �� <br />TOTAL DUE I1 <br />OFFICE USE ONLY <br />SWEEPS t COMP 1 1 LDC CODE DIST CODE AMOUNT DUE I AMOUNT RCVDCHECY /CASH RCVD BY DATE RECEIVED PERMIT t <br />z. i'le"M LGr 7 /0, (70- 7 /S� Y� <br />