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SAN ##QUIN LOCAL HEALTH DI*ICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> L STREET ADDRESS SITE PHONE I With Area Cade) <br /> I 232c� til• =f. �� <br /> T- <br /> Y CITY STATE ZIP CODE I of TANK'S <br /> �at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P G!-1�c.2c E5 has�c.1�,•.�(rss �'1� <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE I (with Area Code) <br /> A <br /> 3e51 I lie 4 3 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION PIPA& <br /> T I osure, Installation, etc.ijaliP,���E <br /> LIFACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> -------- --- — - — ------ -- EXPLANATION— — -AMOUNT <br /> ROBERT H. LEE & ASSOCIATES, INC. 0756 <br /> ' 1337 HOWE AVE.,SUITE 211 <br /> SACRAMENTO,CA 95825 <br /> (916)646.4003 19 <br /> �— CHECK <br /> /„��T-�� ���C t Dollars( AMOUNT <br /> AMOUNT -✓ <br /> Z�f <br /> TO <br /> THE ORDER <br /> OF <br /> \ s� <br /> SACRAMENTO OFFICE <br /> Ar('WEVAMERICA MW 1610 ARDEN WAY <br /> SACRAMENTO,CA 95866 <br /> P PLAN CHECK (Installation or Repair) <br /> L --- — <br /> A <br /> N PLAN CHECK FEE _ $30.00 each SUBMISSION/RESUBMISSION $ 2 <br /> REPAIR <br /> R — <br /> E TANK REPAIR FEE _ $110.00 each TANK I Tanks x $110.00 f <br /> P ----- <br /> A <br /> I PIPING REPAIR/CLOSURE/REMOVAL (Fees are per hour, oinimwi one Dour to be paid on plan subluittal) <br /> R — <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION SAMPLING <br /> (when applicable) INSPECTION INSPECTION <br /> !FEE _ $30.00/hr FEE _ $35.00/hr �.,3, FEE = $35.00/hr $J,-” 0 c' <br /> TOTAL DUE f / <br /> OFFICE USE ONLY <br /> SWEEPS I COMP Y LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY —DATE RECEIVED_ PERMIT I <br /> .^r..f.. .r q:r •: ,w:p.:.M .-t,. •.t44... :.P! 'r rr. .:�,.r, s<C ..r.py wr r.:7..., .a. 1' c, t� <br />