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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> FS C{S Z) a`�j Gtiv uh '-C <br /> A <br /> C <br /> I FACILITY ADDRESS � �7 �� SITE P_HOvN�E� with AREA CODE <br /> L ( - cllly <br /> T I CITY _ STATE ZIP CODE # of TANKS <br /> Y S�G c �� QC�U at SITE <br /> A APPLICANT/BILLING NAME `J APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH-AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I $ <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, <br /> BANK OF STOCKTON 90-103 <br /> `pp�pVL� CO MMKRCIAL SAVINGS TRU.T 1 21 1 <br /> STOCKTON,CALIP OR NIA 27784 <br /> ��� /� <br /> CALIFORNIA CONTRACTOR LICENSE 709109 C-81,SA " /7 7 Q 4 <br /> 808-820 N.UNION ST.,STOCKTON, CALIF. 95207 L �J <br /> P.O. BOX 508 STOCKTON,CALIF. 95201-0508 <br /> PHONE 209/684-8333 <br /> PAY �J\F �� (� L� ► F-1- _,�I DOLLARS <br /> DATE CHECK NO. • <br /> DOLLARS CEO <br /> TO THE <br /> �V i <br /> ORDER OF__ �'�—�` <br /> / STOCKTON SERVICE STATION EQUIP.CO.,INC. <br /> I, <br /> R REPAIR TANK I.D. #(s) <br /> E <br /> P TANK REPAIR FEE = $53.00 per hour (3 hours minimum/TANK) # TANK(s) X $159.00 = S <br /> A <br /> I <br /> R PIPING REPAIR REVIEW & CONSTRUCTION = $53.00 per hour (3 hour minimum per facility = 5159.00) S 5 <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C FEE = $53.00/hr FEE = 553.00/hr FEE = S 53.00/hr <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ................................................................................................................................ .............. <br /> .................................................................................................................. <br /> M00)4V%0000 MOO»OOH)M0100000:001 J000]OC<OO 0000:M.00)Ab X<UO:«0:0:lA\<.>0:00:!!�:<S:-0:0�;«-0:P:P::.:J:v ii}i:.%P:1Ci?:.i:•?:•:::!<-0:!�:<•i:•:::<•:!4>:P:!<4:i:P:�:<P:*�M.�C<O:O?KO Y.N:ttt<0:000%M%0000%00 M0000 M00%0000 MM H0000%00%00%OOM%00%00 <br /> ss'3�E P1f �'COFiF " SOC COS IST CCI)E`:; ` A1fi0U11f RCGI3 Y': :C}{EC1C CASV"'V'FiUY9YVAI? C?f'7E —WOff'r"�»t <br /> s x <br /> 3 a . 5 1 5 a?7g5� <br /> ..........w .................................. ........................ <br /> )w010MI00000 W0)00100 MOJMMOJOM M00)GOON f000%OOOO)OOO![e%0:<N:CLKP:C<O:KO YOMO'Pw>'<N.M!CM:K'!O:i00:!K•:<+!.. P:<ny;w.!..iV.:n:n:HO!:•'!!O i:<h:NA%KN:W%tKO bN%ONOXMMN%OMO MMIMNOJINIMN01.001MM0>•00)tO0 M000O)10►MO► <br /> >SBi ADY fi A01:A AA.1f%e7%AYi A7Df%LOAf'.O�I ASY>Yo`J..>1Y1...`T.Y..>Si:>Y:T.?>.S:.Jl A.::Y'L:Y•Y.;." .^.'.K::7Y.•"Y'^'<•:Y;i:':>;,!`::::::;.`.y.".`.:`:":YAX..wYi tii6:..,X>).Y>."LY�Gf AW A*."=ADlJW"M xx MIX A%>m#A w"00 <br /> Cu YZ n77 rvcv 171;0A1Q11 ft Plop 11 <br /> e <br />