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SAN J0AQUIN COLZTY PLIRLIC HEALTH SERVICES - ENVIROWIENTAL WEALTH DIVSIOII <br />LVID STORAGE TANK PROGRAM - FEE WORKSHEET <br />S FACILITY STTJE NAME FACILITY CONTACT NAME <br />I <br />r <br />E FACILITY ADDRESS SITE PHONE # with AREA CODE <br />a !sv <br />CITY STATE i <br />M of TANKS <br />A et SITEP <br />P APPLICANT/BILLING ?LAME PLICANT CONTACT NAME <br />L <br />i <br />C MAILING ADDRESS PLICANT PHONE 0 WITH AREA CODE <br />A <br />N <br />TCITY STATE ZIP CODE TYPE of APPLICATION <br />F <br />(CLosure, InstaLLation, etc.) <br />TATA <br />MI TRANSFER FEE = 520.00 UNAUTHORIZED RELEASE EVALUATION = $78,00/hr S <br />1 <br />S <br />C CONSULTATION FEE = $78.00/hr SAMPLING INSPECTION FEE = S78.00/hr s <br />TOTAL DUE S�jG�- <br />FOR OFFICE USE ONLY <br />__._....._......»... -----_._........._....._...—.�--.».._»..._......__............... ... _............. <br />:.................................................................................................... .......... <br />_t.....................................................................»..........................................»........................................................r.rr......r..»...............—.—rs- .................__.._ <br />........................................._,...................................,............................................._.......ns...,.,...................... <br />e:::::::::::::;s:::::::::::::r.::::::::::::r.::::::::::::::r.::::::::::::::::r.:::::c::::r.:::::::::::::::::::::::::.................. :: <br />SWEEPS 0 COMPUTER 0 LOC CODE DIST CODE AMOUNT RECEIVED CHECK /CASH RECEIVED BY <br />..............-- -- - I >; <br />EH 23 032 (REVISED 6-21-43) Page 11 <br />DATE RECEIVED <br />