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SAI)*OAQUIN LOCAL HEALTH D•TRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> f FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A --- — <br /> C CITY OF TRACY <br /> 1 -- -- DON MASON <br /> L STREET ADDRESS <br /> 1 SITE PHONE I WITH AREA CODE <br /> 99 WEST 6TH STREET <br /> Y CITY STATE 21P CO E 1 of Tanks <br /> -- D <br /> TRACY _ TA 9ZIPC <br /> at Site (2) TWO <br /> A APPLICANT/BILLING NAME — -- -- ------ _________ <br /> P APPLICANT CONTACT NAME <br /> P CITY OF TRACY <br /> L .._.__.-- -__.._.__— —_ ---^— DON MASON <br /> I MAILING AOORESS --- ---- —_..-- <br /> APPLICANT PHONE I - <br /> 1 325 EAST 4TH STREET WITH AREA cooc <br /> N CITY —__ <br /> S1ATE 21P CODE TYPE of APPLICATION <br /> i. TRACY CA 95376 CLOEUAE, INSTALLATION, ETC. <br /> -- — CLOSURE <br /> ! e CITY OF TRACY WELLS FARGO BANK <br /> 219988 325 E. 10TH ST. PH.209-835-2211 TRACY OFFICE <br /> TRACY,CA 95378 TRACY, CA 95378 <br /> 11-24-1210-575 21996 <br /> *PAY*******180*DOLLARS AND*00#CENTS# <br /> DATE AMOUNT <br /> PAY SJ LOCAL HEALTH DIST, 11/17/89 <br /> TO THE ****#***180. 00 a <br /> ORDER <br /> OF: SJ LOCAL HEALTH DIST. <br /> 1601 E.HAZELTON VOID AFTER 80 DAYS <br /> STOCKTON,CA <br /> 95201 <br /> P PLAN CHECK (Installation or Repair) — <br /> JHPLAN <br /> ----- <br /> CHECK FEE = 170,00 each SUBMISSION/RESUCMISSI011 - <br /> REPAIR ---- ----- --- <br /> rA <br /> AIR FEE = 1110,00 each TANK—_—. 1 tanks x 1110,00EPAIR/CLUSUP,EAROVAL (Fees are per hour, minimum one hour to bepaid un plan submittal)IZED RELEASE EVALUATION COIISTRUCTION INSPECTION SAMPLING I)ISPECTIONplicable) (when applicable) (when applicable) <br /> .00/hr FEE = 135.00lhr FEE = 135,00/hr 1 <br /> OFFICE USE ONLY TOTAL DUE <br /> mmmlRR"�mRmRR mRRRRmMkRmmmmRmR'mRRRmmIm RmR SRR u RR9R mRRRCRRmmRR9 R �RmmRRRRRm�! mlml�mm i,mRRRmSJS.Pi ll f11 mIRRR 0111RmIRmRmNm mlmmRliRMRmIR?.RR!ImIRRRRRa <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CIEC 1/CASH Rr,VD BY DATE RECEIVED PERMIT 1 <br /> ,.__... _ <br /> ..I TNI,II'NN IRIRN R 1RRI!RR. �.RRmRRmR,�III� RRI!IImIRRRRR IIIf OU )ry�i(v C ld Jo kI <br /> "��°��3"1 ;rim I���� a mRmRm!RRmm.I mL .RRRVRf Rm IIRRGVmI mPmRR�mmiioommwma mRRRAr�mRRmm!I IRRRmIRmmRRRRRRRRRRRRR .m!RR IsOimRRm!RIRmmRmmillJ <br />