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SAN JOAQUIN CDUITT PUBLIC NEALTN SERVICES - ENVIRONMENTAL NEALTN DIVSION <br /> UDERGROl11D STORAGE TANK PROGRAM - FEE UDRKSNEET <br /> 5 FACILITY SITE NAME qFALITY CONTACT NAME <br /> L <br /> 1 <br /> T <br /> E FACILITY ADDRESS /' PHONE 0 with AREA CODE <br /> ayp /ll , Cc. �, /inn .c_ �.. � s/ O - 571-7 UZ� <br /> t <br /> CITY STA0 of TANKS <br /> A Sw C/C4' >. Caet SITEPP APPLICANT/BILLING NAME ICANT CONTRACT NAME„L1 <br /> C MAILING ADDRESS ICANT PHONE R WITH AREA CODE <br /> " /JVLe <br /> T CITY / STATE ZIP CODE TYPE of APPItCATIdI <br /> CA 9y�/ (Closure, Installation, eta.) <br /> TOTAL ' <br /> 1986 1987 1988 1989 1 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ !100.00 <br /> A xxxx IOOOI s <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) xxxx xxxx f <br /> 1 <br /> V TANK FEE _ 150.00/TANK (Prior to January 1,1991) 5170/TANK (After Jan3ary, 1, 1991) <br /> E <br /> 0 Tanks = / 1986 1987 1988 1989 1 1990 1991 1992 1993 1994 1995 1 1996 <br /> F (Rultiply Y byby fee for <br /> A each year applicable) xxxx xxxx (�u i� $ 3( O <br /> C <br /> 1 TANK PENALTY FEES ASSESSED xxxx xxxx //u- J / U S 3 cp 'D <br /> L <br /> 1 STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California M t S Code, Section 25287 <br /> T <br /> Y 0 Tanks x 556.00 1988 through 1990 1991 through 1996 <br /> (Enter amwnt and year) <br /> f <br /> [IPERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK ' <br /> C - <br /> - - — 2216 <br /> SUNRIVER ENGINEERING W3aet)121l <br /> & CONSTRUCTION, INC. <br /> 4501-0 O'HARA AVE <br /> BRENTWOOD,CA 94513-0162 <br /> LA <br /> \v� <br /> ^ A \v (00 OLLARS <br /> of Livermore <br /> 'LI 10010RE CALIFORNIA 9-5" OL <br /> 00 !63553011' <br /> WIMMMIJ <br /> 11 - <br /> -- s <br /> [ Cl CONSULTATION FEE _ !78.00/hr SAMPLING INSPECTION FEE • S78.00/hr f <br /> TOTAL DUE S 7- L7 • '/�L <br /> FOR OFFICE USE ONLY s R -*' oc o Sb�j I&IVoI(t --:Z# <br /> .. ��.E. <br /> SWEEPS COMPUTER X LOC COME DIyS�T CODE AIIOIMT RECEIVED CHECK 0/GSH RECEIVED BY DATE RECEIVED 3 <br /> 7 �3 $ <br /> 3 <br /> se 23 032 (REVISED 6-21-93) Page 11 <br />