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SAN JOAQUIN COTY PUBLIC HEALTH SERVICES-ENVIRONOTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />APPLICANT BILLING NAME <br />FACILITY NAME <br />FACILITY CONTACT NAME <br />L <br />_ jcwn u 1 <br />j5 C <br />FACILITY ADDRESS <br />SITE PHONE # WITH AREA CODE <br />/ <br />CITY STATE <br />—�1-ray <br />kl <br />CITY w T STATE <br />ZIP CODE # OF TANKS AT SITE <br />�f <br />LO CA <br />-; D <br />APPLICANT BILLING NAME <br />APPLICANT CONTACT NAME <br />,c1C .l <br />- T �� <� <br />APPLICANT MAILING ADDRESS <br />APPLICAN # WIT//H AREA CODE <br />PHONE <br />/ <br />CITY STATE <br />—�1-ray <br />(D�� <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />Gosure Installation Repair Retrofit <br />1996-1999 2000 2001 <br />$500 FEE INCLUDES FACILITY FEE+ 1 TANK (5170)X(# tanks) X(oofyears applicable) <br />$125 PER TANK AFTER FIRST TANK <br />TANK SURCHARGE = $8 / TANK $ <br />__ __rl 10A PPnrRAM = S101 FACILITY <br />OFFICE USE ONLY <br />AMOUNT RECEIVED <br />SERVICE REQUEST # FACILITY ID RECEIVED CHECK 8 RECEIVED SY DATE <br />SR <br />