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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY NAME FACILITY CONTACT NAME <br /> P)o LZ n1 <br /> FACILITY ADDRESS SITE PHONE#WITH AREA CODE <br /> q s s 2--( ) -35, D_ <br /> CITY STATE ZIP CODE #OF TANKS AT SITE <br /> CA <br /> i <br /> APPLICANT BILLING NAME APPLICANT CONTACT NAME <br /> APPLICANT MAILING ADDRESS APPLICANT PHONE#WITH AREA CODE <br /> CITY STATE ZIP CODE CIRCLE WORK TO BE DONE: <br /> losure' stallation Repair Retrofit <br /> ACTIVE FACILITY <br /> 99 2000 12001 2002 <br /> $500 FFP oliwblO <br /> Oo $ 2010 <br /> (CAbk'1�— t 0 foo Sou $ Dol o <br /> 170 $ �o <br /> ftos UPA PROGRAM=$17.50/FACILITY $ 17. 5 <br /> /V\ 1 <br /> 37/TANK #TANKS X$267= $ <br /> r ' S � j�� p Il <br /> T. `� UA C�� l S RE FEE=$267/FACILITY $ <br /> IN \ <br /> PI 14- ��� LLL//i ••• --- <br /> 1111 <br /> TAI �� 1 EE_$712/FACILITY <br /> REF �� /yf j\I('�Qf� ►�0�[lt ( � �,� <br /> TANI �� V, <br /> TANK #TANKS X$267= $ <br /> r ' $ <br /> TANK <br /> PIPING <br /> MISCEI <br /> TRANSF <br /> CONSUL <br /> $ <br /> UNAUTH( r 1 \, ll U Z° <br /> c� s <br /> SAMPLING INSPE.. �y-�S�' ��vuH $ r <br /> ALL FEES ARE BASED ON i HE$8e HOURLY RATE. TIME THAT EXCEEDS FEES PAID WILL BE BILLED TO APP (CANT. <br /> OFFICE USE ONLY <br /> SERVICE REQUEST# FACILITY ID AMOUNT RECEIVED I CHECK# I RECEIVED V I DATERECEIVED <br /> SR <br /> EH 23 032(REVISED 3115102) <br />