Laserfiche WebLink
ano% JUAaUlr,l LuL:AL. HEALTH DISI'RICl- <br /> y U ROUND STORAGE TANK PROGRAM - FEE WORKSHEET• <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> �ayRvN19rJ cii f l <br /> L STREET ADDRESS SITE PHONE 1 Y17X A.E• Cao= <br /> T <br /> S, ao a 3 <br /> Y CITY $IAT "I CODE 1 0l Tanks <br /> QF�ti p� 336 at Site <br /> A APPLICANT/BILLING NAMEAPPLICANT CONTACT NAME <br /> P ajj4_e CGO Qifi�-(/L—�� <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 WIN AREA CODE <br /> C -- – <br /> GERMAN CAR REPAIR 7905 <br /> KARL M. SCHEINUCK, TERRI M. SCHEINUCK <br /> 461 SOUTH POWERS 209-823-3853 <br /> MANTECA, CA 95338 / 19 11.%71210 <br /> r <br /> PAY <br /> T THE <br /> O DER OF <br /> Q�Be f America <br /> Mai c:a0lu h 0143 <br /> P Elc,k10722 <br /> FOR <br /> 11'00 790 511':{1. 12 000 3 581: 0 14 3 5 0966811' <br /> L <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanks___ a f90.00 f <br /> S <br /> U <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> E <br /> TEMPORARY CLOSURE FEE = 100.00 each TANK 1 Tants s {80.00 f <br /> P PLAN CHECK (installation or Repair) <br /> L <br /> A <br /> N PLAN CHECK FEE = 130.00 each SUBMISSION/RESUBMISSION { <br /> REPAIR <br /> R TANK REPAIR FEE = 1110.00 each TANK I Tants s 1110.00 { <br /> E <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan submittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) (when appli(able) <br /> FEE = 130.00/hr FEE = 135.00/hr FEE = 135.00/hr { <br /> TOTAL DUE f 9 <br /> OFFICE USE OILY <br /> MEM U1111MICUM0111 <br /> SWEEPS 1 COMP 1 LDC CODE 0151 CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> d <br /> 360 F erYtf,1-j — -- <br /> 5 1 <br />