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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> . <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> F FACILITY/SITE-----NAME <br /> A FACILITY CONTACT NAME <br /> ..... - ------- <br /> C 2,Q PAYMENT <br /> I <br /> L STREETDQRE SITE PHONE # WITH ARCA COD <br /> I — <br /> T DEC 15 1989 <br /> Y CITY <br /> E� <br /> ZIP CODE I of TanksSAN J05AQUJN COUNTY <br /> C, at Site PUBLIC11EALTH SERVICES <br /> ........... <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS <br /> APPLICANT PHONE I WIT" AREA CODE <br /> A <br /> N STATE ZIP' <br /> COD kPPLICATION <br /> CR�Skllll. INSTALLATION, CTC. <br /> FACILITY FEE = $100,00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C 1986 1988 1989-1_9a3 <br /> T <br /> I <br /> E TANK FEE = S50.Ofl each TANK <br /> F I Tan 1988 1989 <br /> A ( <br /> tlp�s,,_,_ x $50,00 1986 1907,:u,,lhy,,, appflieaebloOr <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br /> T I z- --X456,00 <br /> Y 1986 1987 1399 <br /> D& Jo <br /> A 11jv JOV ..... <br /> lei C <br /> "'qIRVIp- Oft-r, <br /> W,4 V, Rtjcr 0 <br /> PA To cq - 6-96,6�, At T,at$- x $90.00 <br /> 0&*op 93�?74 03 <br /> I <br /> Adar �z 9 <br /> 707, <br /> FOR TU Z4�CA v,nqs& RI7twlv <br /> F`Ro._P�k <br /> P TANK REPAIR tL, <br /> A PIPING REPAIR/CLO'SUREIPEMOVAL Fees art! <br /> tal) <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPLut. <br /> (when applicable) (when applicable) <br /> FEE <br /> FEE S35.00 EE <br /> OFFICE USE ONLY TOTAL DUE Eli <br /> SWEEPS I COMP A LOC CODE DIS rRDE AMOUUT DUE AMOUNT RCvD CHECK I/CASH RCVD VY DATE RECEIVED PERMIT I <br /> ................... .......... ...... ....... <br /> q111111 qgglipim <br />