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SA0OAQU I N LOCAL HEALTH RIOT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME —�— FACILITY CONTACT NAME <br /> L STREET ADDRESS S SITE PHONE # WITH AREA tOOi <br /> 1 ! 7 e�� per. urn C/Y- 3 <br /> Y CITY STAT IIP CODE # of Tanks <br /> fc y4r�,,, at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L — <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA cove <br /> f: <br /> A — <br /> T CITY STAT I1P'CODE TYPE of APPLICATION <br /> CLOSURE, INSTALLATION, ETC. <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A _ <br /> C 1986 1987 1988 1989 <br /> T _ <br /> I $ <br /> CTAkjv CCC !CA AA --_G Tivv _ �•.-•. <br /> KOIII-FI ITOCKTOK OII+fCR__- . .. • <br /> CALIFORNIA FIRST BANK <br /> -06 WEST NOKINNOOD DRIYK-STOCKTON,CA -3207 <br /> A- <br /> PRECISION INDUSTRIES, INC. Ilio o� <br /> 1041 S.PERSHING AVE. <br /> STOCKTON,CALIFORNIA 95205 n <br /> {209}462-9911 <br /> JL)L, l QTS <br /> PAY ._ <br /> `DOLLARS <br /> mass SOCIA4 TH Ws AT& •Par. �� ���' ! <br /> t -- +'-x 11rTIa16 t7R0 EM.4R.' �°: elm- 1"". 4 :�I.IAOUFiT- sicvwl. Tax - Y x iI <br /> i"4 qq_3 i tri { 1I II ;. 1 <br /> �e tl.�+{ i a1^" '; 1 PR£ 1 iJ INC. <br /> �_ . o <br /> 1 .... HT <br /> 5 R- a <br /> �: <br /> i 'LIR. ' Em. <br /> F -$_..-- <br /> - <br /> �; <br /> REPAIR <br /> R TANK REPAIR FEE _ $110.00 each TANK <br /> E- <br /> P <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 applicable) <br /> FEE = $30.00/hr FEE = $35.00/hr FEE <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> 'WEEPS # COMP t LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD (R #/CASH RCVD BY DATE RECEIVED PERMIT # <br /> 0 1 9 L) <br /> 117R, ' <br /> i�3i kE9�5'cD I'1'T8 <br />