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SAN•OARUIN LOCAL HEALTH D11TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> IF FACILITY/SITE NAME FACILITY CONTACT NAME <br /> ,A <br /> C (�NIOI� l c� �yI�D1(y �NrrN`�o I�eYz2 <r <br /> 1N1TN AREA CODE <br /> L STREET ADDRESS SITE PHONE I <br /> I -f-+ E. Locus-T- <br /> T <br /> Y CITY STATE ZIP CODE I of Tanks <br /> �CqS;-4O at Site I -- ------ <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> I MAILING ADDRESS APPLICANT PHONE I MITM AREA CODE <br /> RECEIVED <br /> A ------ -----_ <br /> N CITY SEP 22 1989 STATE iIP'CODE TYPE of APPLICATION <br /> ----- — - — -- <br /> CLOSURE, INSTALLATION, RTC. <br /> FACILITY F - S per YEAR TOTAL <br /> �A ..------ ... r-- - — - .. _ --._..---. — <br /> C 1986 1987 1988 1969 <br /> 1 — � -- ---- -- <br /> V <br /> E TANK FEE _ $50.00 each TANK _ <br /> F I Tanks x (50,00 1986 1387 1988 1983 <br /> A (multiply 1 by fee for — <br /> C each year applicable) <br /> 1 --- -��—� —� -- - --- <br /> L STATE SURCHARGE = $56,00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> — <br /> T 1 Tanks x (56.00 T 1986 1987 1388 1389 <br /> FERNANDO PEREIRA 743 1499 t — <br /> STELLA PEREIRA r , <br /> 3910 CALIMYRNA ROAD 333-2046 a --- <br /> ACAMPO, CA 95220 ) ' ` "z .5 is / <br /> PA Y THE <br /> ORDER ' __ /� I _ --• - <br /> ORDER OF <br /> DOLLARS <br /> Bank`fSwckton — ----- <br /> IOOi OFFFCE ._-- <br /> 1Nw.WaInu151.,1od1,CA 9520 (� -- <br /> MEMO <br /> �1�4YFJtiG4iES �t4II0A1p3i, -_-_—_ .-.._ <br /> ---------- <br /> R TANK REPAIR FEE = $IIV,VV eacn IAMT L..':"".'_--c.".-._::._:._...'.: <br /> E -- - ......_.. ----- -- - - ..._.._._..._ . <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> R UNAUTHOR17ED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> — - <br /> -- .................. _ ..-_......__...-_...._... .._ ..._...... <br /> FEE _ $30.00/hr FEE _ $35.00/hr FEE = f35,001hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> LIIsIINGMNGGGIG1NGG!NmgINININ9PIGGI 1rG ! mr <br /> L�IN.�INI!Gaw1N:.19!.ViIGuIWI d:Ili1.a,IGaii�ulkl!.:fG111BIGld .11u..V.l.l,,:,ia!J!fi:l!.V.G:..IIu!ILL:Neu:INuIIINIG.IIGIGN:.INJfG!!,.G,1�„ N G <br /> SWEEPS A COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PEP.MIT i <br /> -- ------ <br /> � n 7 �t 1So I s <br /> !rm1!!p�! :u;;97mm u!, lu!r Im 'r ;m l !uuua Iris aur! .ii i! I!111!II L ' t� u! u ' rIN rl;ru" ",!IIIG.IIi.C�ll!! !AGI G!! GP!l9!Vl�l! IGG IIG IIIING! 11.-f NGGNL NiVpNNGG!9N�R6aIGNN,NIII�NGGI!ili <br /> I !our"1i8� , 9N,�, GGuGL...IIG�J�JIG�L..�,INI,NL...,.N_..L,..f..I,..aIJ11GL..uIhLNNuI!!,II!6., �L!1I1GG1,. :.J!I,11dGIGGG�D N � .I � <br />