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SAN JO"UIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> ti <br /> '01ey ie�P /�iz�et�cee �Geai /q/ �' 1 <br /> L STREET ADDRESS SITE PHONE 1 WITH ARCA Cool <br /> Y CITY STATE 21P CODE 1 of Tanks � <br /> �' at Site <br /> F APPLICANT/BILLINGNAME APPLICANT CONTACT NAME — <br /> [ANT <br /> -_-T.- <br /> MAILING ADDRESS APPLICANT PHONE 1 WITH AREA CORE <br /> �f '�vP� 7 — 7S3S <br /> 7 L4L �_._..75— <br /> CITY STAT 21P'C DE TYPE of APPLICATION <br /> GLORURE, INE TALLAT IRN. <br /> _1�1—.>�r�c�<_-?-Qom_____ 9s�yL—__ <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR — TOTAL <br /> RAMCON 371 1 <br /> FIELD ACCOUNT <br /> PH. 916-372-7535 <br /> P.O. BOX 1024 <br /> WEST SACRAMENTO, CA 95691 79 90-3632/1211 <br /> PAY TO TO TILE �0 t� / <br /> OR ER OFM //,''������ $ OO f <br /> �� ILS/ L A R S <br /> CAPITOL <br /> BANK OF COMMERCE <br /> .b0 Cyiltl Mall <br /> 1: 1211363291:0371, 0165907311'01 <br /> JEJ ItIfYURAP,T CLU5URE (Only allowed one time for up to two years) <br /> TEMPORARY CLOSURE FEE = $80.00 each TANK 1 Tanks r (90.00 <br /> rrcs <br /> IP PLAN CHECK (Installation or Repair) — —" <br /> L IN CCIINTV <br /> A - — - - _ — _ _--_—__ _--- �tN <br /> III PLAN CHECK FEE = $30.00 each SUBMISSION/RESUDMISS fall pUELICH� iHpN151 <br /> --- _.— — fiNV]�0 S N't i REPAIR — _ —_— <br /> F, TANK, REPAIR FEE = 1110.00 each TANK '---- <br /> E- 1 Tanks s $110,00 f <br /> A PI G REPAIR/CLOSUP,E T)HIVAL (Fees are per hour, minimum one hour to be paid on plan submittal) �� p a— <br /> R UNAU ASE EVALUATION CONSTRUCTION INSPECTION SAMPLING INSPECTION <br /> (when applicable) (when applicable) when applicable) ' <br /> FEE _ $30.00/hr� FEE _ $35.00/hr FEE = $35,00/hr <br /> TOTAL DU <br /> f o� <br /> OfffCE USE ONLY <br /> WON maim awl, <br /> Z' , <br /> COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT 'CVD CHECK . CASH 'CVD BY DATE RECEIVED PERMIT <br /> _ ._.. _..._,—_.---..._..._._...._...—- <br /> 0 o 371, <br /> I��V9V�gEAII A <br />