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SAN*OAQU I N LOCAL HEALTH D R I CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> {FACILITYISITE-NAME — i -- FACILITY CONTACT NAME <br /> t,NNMENTAL HEA <br /> �s 1 a H K ,T,SERVICES <br /> SITE PHONE # uITN AREA CO0E <br /> L STREET ADDRESS <br /> I -AaC7 y�f . VNL..Dtco l�- dAD <br /> Y CITY STATE ZIP CODE # of Tanks <br /> CA 453-1 ` Lk Site `?7 <br /> A APPLICANT/BILLING NAhE — APPLICANT CONTACT NAVE <br /> P W/ <br /> F' A LTA r-! Ef,4 Cq(N t`Z�Zf r`}..C� <br /> L - --� APPLICANT PHONE # WIT14 AREA COOL: <br /> I MAILING AODF.ESS <br /> -17 S 3? `)z�s rc ti-�.p.,.�C _ tom) -7 3— I 1-7 ? <br /> N CITY1 . } IV <br /> ZIP CODE TYPE of APPLICATION <br /> T LA—) 6S I � � c �� �-iCN�r� lq5Gq ( Ct06t3RE, INSTALLATION, ETC. C,Lb5ujaG i <br /> -_ <br /> WALTON ENGINEERING <br /> 837 RISKE LANE 1319 <br /> WEST SACRAMENTO, CA 95591 <br /> 11-33/1210 <br /> October 10, 19 89 <br /> Poray to the <br /> der of San Joaquin County 335.00 f <br /> -- <br /> Three hundred thirty—five and 00/100 •----------------r— ------------------------ <br /> ' Dollars <br /> Bank of America"'•'• <br /> West Sacramento Brench 0066 <br /> P.O.Box 934 <br /> West Sacramento,CA 85681 <br /> For 21430 Permit Fee 0 CLOSURE FEE = S'30,00'each IANK I t lanksJ z i3a.80 } Z 1 o. a 0 l <br /> U -- - _ — <br /> R TEMPORARY CLOSURE (Only allowed one h ae for up to two years) <br /> TEMPORARY CLOSUFE FEE = S80.00 each TANK rI Ta <br /> PIPLAN CHECK (Installation or Repair) — C <br /> lh <br /> AI _ .ENVIRONMENTAL HEAtrb <br /> INI PLAN CHECK FEE = $30.00 each SUBMISSIONIRESUCMISSION S d <br /> R TANK REPAIR FEE = $110.00 each TANK # Tanks z 1110.00 S <br /> AIPIPING P,EPAIR/CLOSUREIREMOVAL (Fees are per hour, minimum one hour to be paid on plan subaittal) <br /> I <br /> R UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION INSPECTION SAMPLING III SPECTION <br /> (when applicable) (ween applicable) -- (wheys applicable) <br /> F <br /> EE 534.0olklr <br /> FEE = 535,00/hr °O FEE = $3j.00/hr <br /> _-__----_ -- --- - _---- <br /> TOTAL DUE S °C- <br /> OFFICE USE ONty <br /> �It.�!�I,;,;�IS:,t�,i'"�".:Il','I,i U°..u'Ilr�LGs, is�;��,:eta►' '�"�i. i a+.!.':]?'�:�"i�hliles-II' Slli A.'I�ar,:: 5d�4."�t��~ iI�J:V',1�41 'V1Ma.'�luii'r 9' ull;.'':i;;:OJIi!I� C.I5��II I{IIIIIRL•V3;lf'M1hi�a�,G17i14�.�ds1�l�i�t;r� <br /> l� SWEEPS # COMP # LOC CODE DIST CGDE AMOUNT DUE AMOUNT RCVD CHECK )/CASH RCVD BY DATE P,ECEIVED PERMIT <br /> ----- y3� / (tet <br /> �r .. .. 1 - tTf p I11A f �fm 11 �rynA�A <br /> z, <br /> 3f5 r ,I <br /> EI;.I:A�'llln�i�,TYfal�all�i i a i li.l�ti��I H.��d r u i �Ilj. n�nna �4ae �Ifl"F+a'°"" i+�ll Ila �iiAi <br />