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pAN JOAQUIN L.QCAL NGALTa. DISTRICT <br /> / UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> Lis {zi., <br /> L STREET ADDRESS SITE PNON MRN <br /> I A` cave <br /> Y CITY ATE�tIP CODE I of Tanks Lr <br /> at Site r _� <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L- <br /> I MAILING pODRE55c� �G <br /> APPLICANT PHONE 1 MIT" A"aA coot <br /> p _ _ _ --- <br /> N CITY STATE T� tl�'CdDEYFP OAP <br /> T .�iCrc. t L��S gra. ' <br /> FACILITY FEE = 1100,00 each SITE ADDRESS per YEARTOTAL '� <br /> A . _ _ _ •._..._.. — <br /> T 1986 1986 1983 _ <br /> E TANK FEE 1 150,00 each TANK <br /> F f Tanks x tS0,00 WWUW w1986 r�t9GT ry�i988 1989 <br /> A UuIHp y by fee for <br /> C each year appilcable) <br /> 1 � o <br /> T INC. —-- B 12 .� <br /> r)' FILLNER CONSTRUCTION, ^moi <br /> SERVICE STATIONS COMMERCIAL AaLIC. 177928 PH. 16B <br /> 21 TERPRISE BLVD. <br /> WE SA AMEN O, CA 95691 - -- <br /> I I <br /> 9 pNEf OF 1 �/ V �. :. t Y P. .• <br /> i 6 JJf'WWW .. <br /> Bankof Alex Brown USTOMER SINCE <br /> suavesnue see.ivos ,.n 1 <br /> < ,e Yl.ua OHKe <br /> tI Poh OMel9h 90PY <br /> nta,Cdllamla <br /> WA_Y.V�./ <br /> d <br /> ....��...,•., err+.._ ..�.,. —. .......u—.r._......�_.�r...rr+.T..rr.,�,_�..._+ <br /> REPAIR _ <br /> R TANK REPAIR FEE m 1110,00 each K I Tanks x 1110.00 1 <br /> A PIPING REPAIR/CLOSURE/REMOVAL Fees are er h ur, atnlmus one hour to be paid on plan submittal) <br /> R UNAUTHORIZED RELEASE EVALUATION C ST� TION INSPECTION SAMPLING INSPECTION <br /> When applicahle) (V en applicable) When applicable) <br /> fEE = 130.00/hr FEF = 135.00/hr FEE = $35,00/hr t 3 g� <br /> TOTAL DUE 1 3 <br /> UWE VSF ORLF <br /> ,MINE 1 ."W02.21e0 1180 <br /> SdEEPS I 11 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK, i/CASH RCVO BY DATE RECEIVED PERMIT <br /> __.�..,.,..,. _....._._..... _ ,. ...._..,. <br /> `u,ar ICP�lIi99C6�6riPitlE�l !�fG�D�tlbl�kl9,l I,�' d�Iq�V9 " ���V'1V0�9tl �V,,, - <br />