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SAN JOACUIN CCUNTY PUBLIC HEALTH SERVICES <br /> E4VIRONNENfAL HEALTH DIVISION <br /> U RCUNO STORAGE TANK PROGRAM - FEE uORKSHEET <br /> FACILITY SITE NAME uw FACILITY CONTACT NAME <br /> F <br /> C <br /> I FACILITY AC0RR9SS // SITE PHONE % vith AREA CODE <br /> L <br /> t v2 <br /> T CITY STATE ZIP CODE % of TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> 1 MAILING ADDRESS APPLICANT PHONE S WITH AREA CODE <br /> C <br /> A <br /> STAtE ZIP CODE TYPE of APPLICATIONN CITY <br /> etc. <br /> T CLOSURE, INSTALLAT ICN, <br /> TOTAL <br /> 2155 6 �, 1989 1990 <br /> MR.JUN JUE <br /> MRS. LILLIE T. JUE 11-5711210 S <br /> P0. x <br /> P.O.BOoX'04 1046 <br /> EL CERRITO.CA 94530 1, 1991) <br /> SII � <br /> 1996 <br /> PAY TO TME <br /> a, OR <br /> s (lGyfG� >w\ 25287 <br /> 3'. <br /> First interstate Bank <br /> First of Caliiarnia#695 <br /> F.�interstate 4932 Pacitic Avenue <br /> P.O.Box 7485 I f <br /> Bank Stockton,CA 95207-0485 <br /> �1 FOR <br /> n sUY.UU a S <br /> f <br /> tx <br /> U TEMPCRART ttOSURE (A o -time permit, for review d inspocticns TANK J.D. %(s) <br /> R <br /> E TEMPCRAAT CLOSURE FEE - $150.00 each TANK R TANK(s) _ X $150.00 • f <br /> P PLAN CHECK (IMt8tL. Plan Review d Construction Inspections) TANK I.D. %(S) <br /> L <br /> A <br /> N PUN CHECK FEE • $53.00 per hour (8 hours mini" per Facility) _ $G2G,00 minimum S <br /> R REPAIR TANK I.D. %(S) <br /> E <br /> P TANK REPAIR FEE _ $53.00 per hour (3 hours minimua/TANK) % TANK(s) _ X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW d CONSTRUCTION = 553.00 per hour (3 hour mini mum per facility - $159.00) ==S <br /> MCCN T ONS UNAUrNCRiZEO RELEASE EVALUATION SAMPLING INSPECTION <br /> $ q <br /> C FEE $53.00/hr ` FEE = 553.00/hr FEE - S 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> =u <br /> f:n.w �y��...��a <br /> CC10" l OC'C1�"-"b15T"C'CDE1CUAY #C'A) CAEC'K"./CASA'' �xC rO'"3YI��icC.111:O�" A'�cRls ■ <br /> 6-7—M <br /> Cu <br /> s <br /> =s risr s�srarnirsmas.a"an�;-Asa::�+s.s::r•^:rnsm:.-::. �.^'.':`"..`:..,:.:-._..r.=:=xrY�+e.•saa'mrsa.m.a^+sarrsawoi <br /> 7T nil reeve 17/7A/Ortt Fr Pao. '1 <br />