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�., <br />SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />FACILITY NAME <br />FACILITY CONTACT NAfYE <br />L _a5 ��' <br />Sones <br />FACILITY ADDRESS <br />SITE PHONE 04VrrH AREA CODE <br />�)3a a- <br />CITY srwTE <br />lo(z,k4-ZlN Ca <br />(4c,D.gasa <br />_ aP CODE i OF TANKS AT SITE <br />Q52 <br />APPLICANT BK.LIIIG NAME _ . _ APPLICANT CONTACT NAPE <br />YAILNG wooREss 0 WITH AREA COOS <br />CTT'STCTE � i aP cooE �, CRCLE WdtN TO NE DOW, <br />r J + Ci c�V Cko IretaYstipr ehafrt <br />1999 2000 2001 2002 2003 <br />(5W FEE INCLUDES FACILITY FEE « 1 TANK (slm)xt ' <br />$125 PER TANK AFTER FIRST TANK - -- <br />TANK PENALTY ASSESSED_.— <br />TANK SURCHARGE = $15 / TANK <br />TANK ID # (s) _ -. _ --LcLOSURE FEE = $278 / TANK # TANKS X $279 = <br />TEMPORARY CLOSURE <br />Plan Renew &W UNpectom) <br />TANK ID # <br />= $279 / <br />TANK ID # (s) I PLAN CHECK FEE = $741 / FACILITY Is <br />OFFICE USE ONLY <br />SERVILERBDLI 11I FACILITY ID AMOIINi <br />SR B11® RECGECKf RECBVBp BY DATE RECEIVED <br />8123 W2(REVISED HT ) <br />