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SAN JOAQ)IN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL WEALTH OIVSIOM <br /> UNIFRCRC U D STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> -FACILITY SITE NAME :01rjlb' <br /> D• Y� <br /> sE FACILITY ADDRESS <br /> SITE PHONE U with AREA CODE <br /> ;40 1!L eek <br /> ITY STATE ZIP CODE N of TANKS I <br /> frzk+on <br /> A ��y at SITE <br /> P APPLICANT CONTACT PANE <br /> P (APP1.I[ANT/BILLING NAME /1 <br /> 1 _ri�Pa- � 1(�r�n � lD*1sMAc�t(i+� <br /> I - - APPLICANT PHONE U WITH AREA CODE <br /> C MAIN ING ADDRESS <br /> A u 0 I-Db-+laru_ venues 510- 51l9-OI(02 <br /> „ ____.. <br /> I CITY STATE ZIP CODE TYPE of APPLICATION p$U.) <br /> n y,�--_ ` CA 014513 (Closure, Instellatton, etcJ <br /> Ore n I WOVCi TOTAL <br /> 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 %%%% %%%% (oD <br /> A I CID <br /> C 5 <br /> 1 FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX <br /> 1 <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> U Tanks 1 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> r (multiply U by fee for <br /> A each year appliceble) XXKX X%XX 7 Q .�`(� e 5 <br /> C <br /> I TANK PENALTY FEES ASSESSED XXXX XXXX 5 <br /> L <br /> 1 STATE SURCHARGE a 556.00 each TANK (Due every 5 years) See Calffornfe H t S Code, Section 25287 <br /> T <br /> T e Tanks % 556.00 1988 through 1990 1991 through 1996 <br /> (Enter anent Ind year) <br /> C PERMANENT CLOSURE (Rem +U <br /> oval or Authorized Closure-in-Place) P"MM <br /> 0 CLOSURE FEE - 578.00/hour (3 hours mInin WTANK) REOGI X $234.00 5 2'71.0 <br /> S — (t� <br /> U TEMPORARY CLOSURE (Plan Review t Inspections) NUS I.p•7U(�y) <br /> .. . _. _ — - — N COUNTY <br /> ---•--- <br /> SUNRIVER ENGINEERING <br /> ENVIRONMENTAL HEALTH DIVISION 2191 <br /> IN <br /> & CONSTRUCTION, INC. �,,,,R„ <br /> 4501-D O'HARA AVE. 510-516-0162 <br /> BRENTWOOD, CA 94513 <br /> Ti <br /> owl,'-i nF. V l <br /> Ir' _4 V ��.,P._ Urn f P S �O _rJ� ( OO LLARS <br /> h}I <br /> Bonk of Livermore <br /> C{ 205 SFCOND STRFET-LIVERMORE,CALIFORMA 9F550 <br /> FnR - <br /> 00 L635530,16 <br /> FOR Uf FIFE 115E ONLY <br /> Fl9m'4^'9'A9E'�ml'T'9'^ IT' T55:P.m5RIRF^'vm"'v vpn r-mrr' JT^.:^•.....r:^m.. T'T'"P R <br /> L li!SI T . ..inn a .nl . vl. . r r..lv .. I r .. <br /> I rS a COMPUTER U I LOC CODE I DIST CODE I AHO181 RECEIVE I CHECK U CASH I RECEIVED BY DATE RECEIVED 9 <br /> ',',K/K/!lgllgfl <br /> -,� r !m^ c TOWN m� r5 '"' T- ' :: ... ml:ar w T T-^"nrr <br /> v i. i...:L....i: . I ....:�:.....Ld91 di aP:..i.IF.1.J I-!; <br /> :nl <br /> EH :3 052 (REVISED 6-21-93) Page 11 <br /> t <br />