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SAN wAQUIN COUNTY PUBLIC H2.,,LTH SERVICES <br /> UNDERGROUND STORAGE tANK PROGRAM . FEE WORKSHEET <br /> ACILITY/SITE NAMEACILITY CONTACT NAME <br /> I <br /> TREE! ADDRESS ^ ITE PHONE I WITH AREA CODE <br /> CY\, I <br /> ITY TATE IP CODE of Tanks <br /> -� or ap11 `1C2-'i tSite <br /> PPLICANT/BILLING NAME PPLICANT CONTACT NAME <br /> I ILING ADDRESS PPLICANT PHONE 0 WITH AREA CODE <br /> ITY TATE IP CODE YPE of APPLICATION <br /> LOSURE, INSTALLATION, ETC. <br /> ACILITY FEE • 5100.00 each Stta ennaeee ..... vet• <br /> DATE REF NO. AMOUNT <br /> FALCON ENERGY <br /> ASSOCIATES 'y 4205 <br /> 8500 SO.AUSTIN RD. <br /> STOCKTON,CA 95213 11-35/1210 <br /> 7f <br /> PAY I,'- ' C� .Y� DOLLARS <br /> DATE PAY TO THE ORDER OF CHECK NO. OROSSAMOUNT DISCOUNT CHECK AMOUNT <br /> DESCRIPTION <br /> BANK OF AMpOp WERE-STTOCKTTON,CA 952p1TER aR.0155 , <br /> ti 112004205D• 1: <br /> LAN CHECK (Instellatidn Or Repair) <br /> LAN CHECK FEE • $30.00 each SUBMISSION/RESUBMISSION <br /> EPAIR <br /> ANK REPAIR FEE • 5110.00 each LANK N Tanks It 5110.00 <br /> (PING REPAIR/CLOSURE/REMOVAL (Fees ere Per hour, mmni" one hour to be paid on plan submittal) <br /> AUTHORIZED RELEASE EVALUATION ONSOUCTION INSPECTION AMPLING INSPECTION <br /> when applicable) when applicable) when applicable) <br /> EE = 530.00/hr EE • 535.00/hr EE = 535.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> vaQe__._.______ _____________________________________. <br /> va�mF•oarssa,e7vevavaa:maa.... _____ ...........avovavamaavam <br /> ma auaaa•au•ae anuuauaasuumuBY a =avuauu aeaaA•u•u <br /> s SWEEPS s COUP R LOC CODE DISI CODE AMOUNT DILE ANOINT RCVD CHECK M/CASH RCVD DATE RECEIVED PERMIT R ° <br /> :1 a <br /> f �'a"va"aae sa��a�aam"amamaamv�amamaamS--LL- e�ama'maeeam'a'o <br /> auwamaauaa•euauuaa•aaa•eu=aau uaaeaaa umuer <br />