Laserfiche WebLink
SAM JOAQU I N <br />I Imo, KL LC , L <br />LOCAL HEALTH D iSTR I CT <br />UNDERGROUND STORAGE <br />TANK PROGRAM - FEE WORKSHEET <br />P <br />�F FACILITY/SITE NAME <br />FACILITY <br />are per hour, minimum one <br />A <br />R UNAUTHORIZED RELEASE EVALUATION <br />CONTACT NAME <br />SAMPLINGINSPECTION <br />C � u EfAm STAtT\otl MML1 <br />MAszT <br />�iZAtix otZ S�H++1 <br />-_•._ _-__ <br />FEE - $30.00/hr <br />L STREET ADDRESS <br />— ^ FEE - $35.00/hrI <br />SITE PHONE 1 WITH AN94 Cmmm <br />I I ADS MA xR 't�T• <br />T —_ <br />109 . 835 -7 (OZI <br />Y CITY <br />STATE <br />'ZIP CODE I of Tanks <br />Es�a►�on! _ <br />CA <br />g53Z0 at Site 3 <br />P APPLICANTIBILLING NAME <br />'APPLICANT CONTACT NAME <br />P 1 R�.0\StDA� TnIUuS'I"Q� S Zr1L. <br />V <br />KEN AiN-b ex, kx <br />L <br />I MAILING ADDRESS <br />L IDLII . PE ,�IhiC,, AVE <br />APPLICANT PHONE t WITH A1191, COD[ <br />__.. --�-- <br />- 9QII <br />N CITY-__....�_Tw_ <br />T 'E a GALT c�. nj <br />_ <br />STATE <br />Gil <br />_zea _ytvz__ <br />r -i IP CODE— TYPE of APPLICATION <br />`� �ow"'""'' a o++•r2.`�CA,t <br />�_._._. _._ <br />S Lq Eo R <br />'��”- �T <br />1 riY Pti__11M n(I....L..C.t_ft <br />_....—�.„»._-..__....—�„_._ •-- <br />.Annncce --- urIn._.......—...^ <br />___.�� <br />PRECISIONINDUSTRIES, INC. <br />NORTH STOC KTON OFFICE <br />UNION BANK <br />900 WEST RONINHOOO DRIVE - STOCKTON, CA 95207 90-49 <br />1041 S. PERSHING AVE. <br />1120 <br />STOCKTON, CALIFORNIA 95206 <br />(209) 462-9911 <br />5599 <br />PAY <br />DOLLARS <br />4 <br />DATIE TO THIS ORDER OF GROSS SOCIAL INCOME STATE <br />• AMOUNT SECURITY RlTY TAX TALC =•D•i. <br />1 <br />-rites I � hY CCU � <br />)^r CD D r' <br />PREC 10/,x,-N1\!11Us 'IES, I_ C. <br /> <br /> <br />PLAN CHICK (_Installation or Repair) <br />FLU CHECK FEE a $30.00 each SUBMISSIONIRESUCMISSION <br />REPAIR -- PL PA t j� L - <br />I Imo, KL LC , L <br />R TANK REPAIR FEE _ $1I0m each <br />TANK <br />1 Tanks 1 K $110.00 <br />P <br />A PIPING REPAIR/CLOSURE/REMOVAL (Fees <br />are per hour, minimum one <br />hour to be paid on plan submittal) <br />R UNAUTHORIZED RELEASE EVALUATION <br />f CONSTRUCTION INSPECTION <br />SAMPLINGINSPECTION <br />(when applicable) <br />(when applicable) <br />(when applicable) <br />-_•._ _-__ <br />FEE - $30.00/hr <br />FfE - $35.001hr <br />�.5...--..�� <br />— ^ FEE - $35.00/hrI <br />TOTAL DUE <br />OFFICE ISE ONLY <br />I <br />$ 1�© Q2 <br />5W€EPS t l COMP 1.` �LOC �COOFj DISI COf)fj AMOUNT DUE I AMOUNT RCVD�—CHECK 11CASH 1 -Rr;VD DY.1 DATE RECEIVED f PERMIT t <br />