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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> I FACILITY ADDRESS SITE PHONE N with AREA CODE <br /> act( E T- wi <br /> T CITY STATE ZIP CODE N of TANKS <br /> Y at SITE l <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> 1 MAILING ADDRESS . APPLICANT PHONE N WITH AREA CODE <br /> C <br /> A <br /> N CITY 0 C T 11 1990 STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> FACILITY FEE • $100.00 each SI Rpyg(tTWES TOTAL <br /> le <br /> ---- 1mi 100a too. 1o0c 10n6 <br /> OIL EQUIPMENT SERVICE N� 15545 <br /> DIV. OF KEITH A. TALLIA, INC. <br /> P. O. BOR 860 <br /> 760 INDUSTRIAL WAV 208-764-1608 11-67/1210 <br /> SAN ANDREAS, CALIFORNIA 86240 <br /> 18 I <br /> PAY TO THE <br /> ORDER OF <br /> First Intestate Bank <br /> F� First of California <br /> IIIon Andras oM <br /> terdt�e 169 E steSt. Ch rles Street <br /> Bank San Andreas, CA 95249 <br /> A <br /> H PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION (1st 2 fire. of review) E <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each SUBMISSION/RESUBMISSION N Tanks x $110.00 f <br /> E <br /> P <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, mini mm ane hour to be paid on plan submittal) <br /> 1 <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when applicable) <br /> FEE = $30.00/hr FEE = $35.00/hr FEE _ $35.00/hr S <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> :Y:6w'a::»z:ii: ......ia:iw <br /> .1��R-�•-yaw-x�•'�-ray jmvr9r �r • err€ r� sr�•fiu v% �r r - aa�r�r e. <br /> a <br /> a...._....„ -� -� $ <br /> _. .... <br /> ...:.... ....... I I '�tJ <br /> = 01 P> AIS w S <br /> wwnwatiiwiw4itiwtiirw wiiTiar irwwwxwrinwiwixr xew r.wwwxw� i witrtwwiiwrwwwrrww" <br /> rtrsnaw.wfwsswAawpeAwAewrAgwaawArrfMasAseMswNxsaaaaramoaaaw,aw aw Axmm awxaseaexawaaea'r�wtnnxma reraaa awsw werfrwrxwaosxve%cnxscaxe,xxerra <br /> FII 73 012 fREV 6/90) it Pnne 11 <br />