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BAN JOAQUIN LOCHL HEALTH DISTRICT <br /> 61ERGROUND STORAGE TANK PROGRAM - FEE WORKS* _ <br /> CILITY/SITE NAME FACILITY CONTACT NAME <br /> Brett L. Winquest Brett L. Winquest <br /> C <br /> SITE PHONE 1 (with Area Code) <br /> I' L STREET ADDRESS 4627 E. Main Street <br /> T SPATE TIP CODE 1of TANK'S <br /> Y CITY Stockton,. CA 95205 at Site 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Same Richard Thorpe <br /> P <br /> L APPLICANT PHONE 1 (with Area Code) <br /> I MAILING ADDRESS (209) 941-4527 <br /> C <br /> TYPE-of APPLICATION Tank Removal - <br /> 2 <br /> A. <br /> tMIt CMtGC t OELIV61.[O OVNT�tNT - -- <br /> RICH -MART 10842 <br /> JIM THORPE, DISTRIBUTOR OF QUALITY PRODUCTS <br /> 19_ 388-8175 402-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 <br /> 10.103/1211 <br /> LODI, CA 85241-0357 QQ <br /> 191cA4 <br /> PAY d d <br /> TOT• TO THE c� <br /> ORDS IS /D <br /> i DISCOUNT <br /> ` •MDVIJT=�=Nt=N d7h _ DOLLAR <br /> .Bl'UaIC., <br /> 1001 OFFICE <br /> 110 W Wdnw It,loth,G%240 <br /> Irvcs — - <br /> tem <br /> l <br /> O CLOSURE FEE —1 1 Tanks_ 1-- 1 $90.00 $ 90.00 <br /> SU _ $30.00 each TANK <br /> 5 <br /> D TEMPORARY CLOSURE (Only allowed one tine lot up to two years) <br /> $ <br /> E TEMPORARY CLOSURE FEE = 180.00 each LANK 1 Tanks----- a $80.00 M ENT <br /> P PLAN CHECK (Installation or Repair) RECEIVED <br /> L r. P ?.. 6 1930 <br /> N PLAN CHECK FEE % $30.00 each SUBMISSIONIRESUBNISSION f <br /> REPAIR ENV IRQNNil EN1�- <br /> I, N <br /> R1 Tanks_____ a $110.00 $ <br /> E TANK REPAIR FEE = $110.00 oath TANK <br /> P <br /> A <br /> I PIPING REPAIRICLOSUREIREMOVAL (Foos are per hour, siniaos one hour to he paid on plan subeitta <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> FEE = 130.00/hr <br /> FEE = 135.00/hr FEE _ (35.00/hr $ <br /> TOTAL DUE 1 90.00 <br /> OFFICE USE 01Ly <br /> SWEEPS-f- OMP 1 LOC CODE BiST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVO BY DATE RECEIVED PERMIT 1 <br /> `1( c1u 6 32 }b°° <br />