Laserfiche WebLink
Aak <br /> --- - - -- <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> f UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FI FACILITY/SITE NAME , FACILITY CONTACT NAMMEPAYMENT <br /> Y M EIVT <br /> III F. 2 S� v <br /> L STREET00$ES SITE PHONE I WITH AREA CCD[ <br /> T <br /> � � � DEC 15 1989 <br /> Y CITYi 1ATE 21P CODE f of TanksSAN JWUIN COON <br /> � (�Lk4--cc7N\ {1 at Site PUBLICI6EALTHSER`.'ICES <br /> A APPLICANT/BILLING NAMENY RONM" <br /> APPLICANT CONTACT NAME <br /> I MAILING ADDRESS APPLICANT PHONE I WITH AREA COD[ <br /> A <br /> N CIJy� STATE 2IP COD PPLICATION <br /> 1 ���il�' �. -�� ��2'L? CLO... IM/TALLATI.., CTC. <br /> FACILITY FEE _ $100.00 each SITE AOO2ESS per YEAR J 10TAL <br /> A ----------_ — <br /> C 1986 1987 1988 1583 <br /> T <br /> I f <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks s $50.00 1986 138] 1988 1989 <br /> A (:ultipiy-f by fee for —F— <br /> C each year applicable) $ <br /> I <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> T 1` ti.f56.00 1386 1987 1988 1383 <br /> DBA TI?y LH N J j� - <br /> 1z3z FAIRVI WCONS �_ --- <br /> oAY ro rH TV�ARF q�9' 666-6 o7*10 T Aks— z $30.00 f Z <br /> O FF 327q 3 <br /> AC N 0490 f <br /> 11.80 <br /> I FOR lAR C, FRI1y AVB "A <br /> Y 4.7 No ro 270. .` f <br /> R�TANK P,EPAIR I'LL 1 f <br /> E — --— <br /> P -- --- -- <br /> A PIPING REPAIR/CLOSURE/REMOVAL (Fees are tal) <br /> R UNAUIHORI2ED RELEASE EVALUATIOT NSTRUCTION INSPtLI.. <br /> (when applicable) hen applicable)FEE _ $30.00/hr E _ $35.00/hr FEE _ $�o. f — <br /> --- --r -�----- - <br /> j— TOTAL DUE f 2 u <br /> OFFICE USE ONLY <br /> ! ��, GGuiG��GGGCGiiGGGGG1i��G'Vi9i.ssGG�IGGGGGGGGGGG!L�GGG "GGa"GiGav'�G� ,: a . G�iGGV"u��LufGiGGGI"�G';"�GGMG!�]GiiGCiIG �GGftr��GJNGIT�GCYGG1GGG! <br /> SWEEPS I COMP I LOC CODE DIST COOE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I 1 <br /> a^,ftiI rmurtq� T'I�Gm r &"fi�GI�GG" �NG! iu. I ri <br /> Ei7`DOt kEU�5�0 I�78�" G�G�IGGGI� 9lGlGyI11,11 IM312, 111.00AVRGIGGRGwifiGGG� d6i�W9G1liGGCII1 <br />