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• <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F � / f <br /> C <br /> I FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 3-6 -3-3 ). k Cr�� <br /> ICITY STATE ZIP CODE # of TANKS <br /> SLY r 1 � Ch at SITE <br /> A APPLICANT/BILLING NAME / APPLICANT CONTACT NAME <br /> pry fT�'� I�1FC Cir+ P�aN w� � ri <br /> L <br /> I MAILING ADORES r� APPLICANT PHONE # WITH-AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> Tf1� 17C� Z=[ c� Z� CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> 1985 1987 1988THI�� <br /> P.O. Box 1556 ^M1 -- $ <br /> a Santa �iosa, Gag _ u ��_ V <br /> 5402- <br /> <br /> ^ <br /> MAIN OFFICE CHECK LJ <br /> SANFA ROSA,CA 9540 i NUMBER <br /> PAY THE SUM OF 159 DOLLARS AND 00 DATL <br /> /100 CENTS 1-11-9I <br /> 159.00 <br /> TO H IE <br /> ORDER COUNTY OF SAN JOAQUIN <br /> OF <br /> L — <br /> A — - - - <br /> N PLAN CHECK FEE - $53.00 per hour (8 hours minimum per Facility) = $424:OU <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) _,L X $159.00 = S cN7 <br /> A <br /> I <br /> R PIPING REPAIR REVIEW 8 CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = $159.00) 5 <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = 553.00/hr FEE = $ 53.00/hr <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> .................................................... ..................,............................................................... <br /> ]OOP NW i0.'W>.NJP)0490P`001p000D NW%PP)ONNOOOP i00W Oav h*ih^4%0F%i400 X<i•:�S;L::w;O»;.i•::a:o::•.ia::-0•:iri::::.:.?:.::•.'.??':-0:;i?;:•;.•:':::::i`:: :i•i:.:•?:•`}:iJ.Ov:<s WJNCIXLkVPX<PW 0049 i60p%OWP:MDI0000F xNOVC00 NOF NGi9P NOP 14G400P09P oiP iWO <br /> d Co' o ''i 015 :.,: �: is7'coir '"'�:'::a),�o �rY'izcv�..:. c`cx" ')cAs'H ,}�,_ ..� 'TAT?TMNE°�` � ( " }ter <br /> N <br /> NW NOF NA04P0000 iOFCOF NOF Am NW OOW SAM]W0%`0004 Xi4;cc^Ou:iM:ui:-0:S?tr:i?P%L.X{::C:{:".:�:'4::::`:.:4:%.::.:ii:!:i, :+:<•:4:{t<(4:i<4:Ci[e0 NO3•%eiOb N04]FOF N000F TNP km NM NPF wo NW=NWPFNOP;W <br /> � �SKR�f7S�SW��1'�. 5�.�.`'AWfSC.�ktvw.}.�-'iiS�r,i:'ii:3�:fJn•�.\h- i } ::... ... ....... ....._...�.....n S }MK' i' YZ.�Y . 3��1{= 1�. W1� }� <br /> Pu ;)7 nz:) IPPV 1;1/;)A19n1 ft P oe 7T <br />