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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> A FACILITY/SITE NAME FACILITY CONTACT NAME <br /> L STREET ADDRESS <l <br /> 7 -7— SITE PHONE f M1rR AREA CODE <br /> T— //7� �TG.L. S/G cr L. .. ct'••-i is _ ; _ %� <br /> Y CITY ._ S ATE TIP CODE f of Tanks <br /> t Tis_ )C.- at Site <br /> A APPLICANT/BILLING NAME - APPLICANT CONTACT NAME - - <br /> P <br /> P GNf/Clc 2 (l l• Cc C/% c. Li <br /> I MAILIN ADDRESS — <br /> C CI c APPLICANT PHONE f w1rH AREA coot <br /> A - 1--- _ __ > yi 7 <br /> T CITY - <br /> 44 STAT ZIP'CODE TYPE of APPLICATION <br /> C"h74�� C� (r=7- C "> Z CIOEURF. IR9TALlAT tON.'CTC. <br /> THIS CHECK 13 IN PA. MEN T OI THE FOLLOWING <br /> LDON & COWELL CONTRACTING "`-F�WE=LDONN, <br /> P.O. BOx 69 s / _ , . 0661 <br /> --•----- <br /> HICKMAN, CALIFORNIA 95323 <br /> (209) 874-3722 <br /> FAX (209) 874-3723 <br /> CENTRAL BANK -"--- <br /> !� WATERFORD, CA 95386 90.2067/1211 _ <br /> PAY <br /> DOLLARS --- <br /> IL DATE CNECK NQ AMOUNT <br /> TO THE <br /> ORDER OF <br /> T C/ <br /> y OVER $500.00 2 SIGNATURES EQ IRED <br /> AUTHORIZED SIGNATURE <br /> 1110001111Lill - 1: 12 1120678i: 030202413811E ---- <br /> R TEMPORARY CLOSURE (Only allowed one time for up to two years) - -- <br /> iEMPORAP,Y CLOSURE FEE = $00.00 each TANY, f Tanks x 190.00 S <br /> P PLAN CHECK (Installation or Repair) ------ <br /> AL <br /> N PLAN CHECK FEES $30.00 each SUBMISSION/RESUOMISSION $ <br /> REPAIR -----._........_ <br /> P• TANK REPAIR FEE = $110,00 each TANK - <br /> E- f Tanks x $110,00 $ <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, minimum one hour to be paid on plan suboittal) _ <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION _T - <br /> (when applicable) (when applicable) (when applicable) <br /> _ ---'----- .. <br /> FEE _ $30.00/Ilr[ FEE = 135.00/hr FEE = $35,00/hr $ <br /> TOTAL DUE $ e- <br /> OFFICE USE ONLY <br /> „!A!V��OI'�CCCGV9I�IICVICICCImVCCCVVI�!PII99CVG4!CmIVrVI@ IVIV6 .I, .I^IuiilVlfl�Cln;'VCVVGGIICCGC ."!1!V911VVNVuVC!!191C�liVVVC !IICVr! ' '��GCIGGIVIViC6i!II!I@IG!1"ifuGIi1116�.CIGCVIICIIGMV!VIIIiiIIIGVG!IfL!I�III� 9VGI,�Ii�VICI!Ilf?iIVVIC!VIICV.Cj' <br /> SWEEPS f COMP t LOC CODE .DIST CODE AMOUNT OUE AMOUNT R VD CHEF, CASN RCVD DY DATE RECEIVED PEP.HIT C <br /> �I'1�TI Vpll 11,1111 IIJ' I '��!ICCCCGI�ILIG�IGI,C!�IC!Ii9VV iGlil!:1111ICVIII���rIIGCIC�C�IVIi�iC�I �CCVVVIiIVJI VINE I �9V�IIV.�IIVI CV�9VII VI'i I�! I — II � I I i i o <br />