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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> TY/SITE NAME �i.NDERGROUND STORAGE TANK PROGRAM - FEE YORKSHEET <br /> A"FACILI -_ <br /> FACILITY CONTACT NAME <br /> L STREET ADDRESS <br /> Y CITY PHON I Y1TN AREA Cmmf <br /> c GL''i�TOiJ/ ST IP CODE 1 of Tanks <br /> A APPLICANUBILLING NAME at Site <br /> P <br /> L sGrQrs� APPLICANT CONTACT NAME <br /> 1 MAILING ADDRESS <br /> AP CA PHONE <br /> YITN AA[A Coo[ <br /> SEIBOLD CORPORATION <br /> P-O. BOX 30577 209-848-2152 1240 <br /> STOCKTON. CA 95213 <br /> I <br /> 9D414e/1211 <br /> t <br /> PAY <br /> TO <br /> _19�ef <br /> ORDER OF <br /> DOLLARS <br /> 2441 East Main Street' <br /> SlacktOn,CA 85202 <br /> FOR <br /> 11000 1 2400' 1: 1211414821: <br /> 01 6046 u• — <br /> L rc1 nnncni 1 cwum�xemoval-or <br /> aosure-in-Place) --- <br /> 0 CLOSURE FEE • 1.10.00 each TANK <br /> S 1 Tanks <br /> U x 130.00 <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = 180.00 each TANK, —� <br /> 1 Tanks __ __ x 190.00 1 <br /> P PLAN CHECK (Installation or Repair) rMY,1r1G1Yr _ <br /> L <br /> I PLAN CHECK FEE = 170.00 each SUBMISSION/RESUCMISSIO)I -- �— <br /> MAR 0 R 1990 <br /> REPAIR <br /> NMI P, TANY, REPAIR FEE - 1110.00 each TANK -%fWNM �� LTH �V,FtVI�� '--- _ <br /> E - I Tanks <br /> A ------ <br /> A PIPING REPAIR/CLOSUD,E/REMOVAL (fees are per hour,—min-_," _•mum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION <br /> (whe_aPPlicable) lvhST UCTIO applicable) SAMPLI—p—C <br /> FEE = 170.00/hr ----•- --- (when applicable) <br /> FEE = 175.00/hr FEE _ {75.00/hr <br /> OFFICE USF ONLY TOTAL DUE 1 <br /> @N11�9,' 1611�V9U@VIVOOR@�ll!! 19Vf�!�lfl'IVp91UlIDVV'�pNtl.HSV 'NVVPJIiu41VMOCV9VIIVfiVaVi4l�liN":3OIV@OgIuQVI�iD + . <br /> SNEEPS 1 COMP 1 LOC CODE DIST CODE ANOUIIi DUC AMOUNT R.rCA!ytip@ � rK�I��/IIS@�S@H!@aI! !IfVDDYIIII�IrI�DnTIE�IP.ECIF�ICoIII@ J�CI�PM�J( 'm��@q! <br /> ._ __.—_— <br /> '!��l CR T7 �I�jij, �U�M@pl+@C948VIllG@GGi 1919iIPP�'I!114'@li aimllfVffi�IVP�'GI@�T � � <br /> F,�, � Fv �b l frrrt�uur@�I@I@I@II@,�@@virl�rmR@V tllNimlp1,11118 uMloi,,- -8 ) <br /> i -- .n1111,nIIIIPU�IIImIIfF,in4gnnpllA�nm 17i�pannn ��unmmn,mm�.il„ <br />