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SAN JOAOUIM COUNTY 'C HEALTH SERVICES - ENVIRONMENTAL HEALTP 'ION <br /> URDERG, STORAGE TANK PROGRAM - FEE WORKSHEET <br /> MARE FACILITY CONTACT NAME <br /> Athony Azevedo Anthony Azevedo <br /> ADDRESS SITE PHONE S with AREA CODE <br /> 620 S. Central Ave. (209)3391914 <br /> STATE ZIP COD S of TANKS <br /> Lodi, CA 9521 at SITE 1 <br /> APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I Same as above Same as above <br /> 1 <br /> C MAILING ADDRESS APPLICANT PHONE / WITH AREA CODE <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY <br /> (Closure, Ins to I Iat ton, ate,) Removal <br /> TOTAL <br /> 1986 1987 1988 1989 i990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) 1100.00 <br /> S <br /> A <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applleable) %%%% %%%% 5 <br /> I <br /> V TANK FEE 250.00/TANK (Prior to January 1,1991) S170/TANK (After January 1, 1991) <br /> E <br /> R Tanks • 1986 1987 1988 1989 1990 1991 1902 1993 1996 1995 1996 <br /> F (multiply R byby fee for <br /> A each year applicable) S <br /> C_ <br /> I TANK PENALLY FEES ASSESSED %X%% %X%% 5 <br /> L <br /> I STATE SURCHARGE a 556.00 each TANK (Due every 5 years) See Cal ifornle N S t Cade, Seetlon 25287 <br /> T <br /> Y S Tanks_ X $56.00 1986 through 1990 1991 through 1996 <br /> JIM THORPE OIL, INC. 4162 <br /> C P( DISTRIBUTOR OF DUALITY PRODUCTS <br /> L 351 NO. BECKMAN RD. 368-6175 462-4581 ' <br /> 0 CI P.O. BOX 357 <br /> S LODI, CA 95241 qq � 90-844/1211 <br /> U TI 19U <br /> R <br /> PAY <br /> E it TOTAL TO THE //�) d '7/ <br /> ORDER 0 $�� D�tt� pZ3UU <br /> O,fCOVNt vo 7I <br /> P R v <br /> L -..DOLLARS <br /> A <br /> N P. FARMERS & <br /> MERCHANTS <br /> ILII BANK 8MM€oda b <br /> R R' <br /> E <br /> A T 004 i6 1211' z <br /> I rj <br /> R - <br /> PIPING REPAIR FEE • 578.00/hour (3 hours minim_/FACILITY) f 5236.00 minim_ t <br /> N TRANSFER FEE • 520.00 UNAUTHORIZED RELEASE EVALUATION 578.00/hr 5 1 <br /> 1 `t <br /> S : <br /> C CONSULTATION FEE • 178.00/hr SAMPLING INSPECTION FEE a t78.00/hr t <br /> TOTAL DUE 5 234.00 <br /> FOR OFFICE USE ONLY <br /> m: <br /> -:: 5.. . nmmi 'p-uN�w�i�i!.�m�{�m ' ibo"nMO:! <br /> SUE EPS R COMPUTER R LOC CODE DIST CODE AMOUNT RECEIVED CHECK S/CASH RECEIVED 8 DATE RECEIVED <br /> o Lr� S Z q <br /> msmm.. stnn!n .!::nnmmxm!mm!!ms:!::�:mm^.^n!!!!sm�em!a:::m!!!;enr.!eoet �!!mme:!m! -.: .ememve�;.mmsm ^'!!.^.ms!. . _ .m:x._......:_�m!i <br /> ... ... Mlm ^" <br /> rma_me!isumxertau:�us!^—. 'u—ata: nPim�q:- '-_' -,. nfi°Jli^� nl{nfii'2L141't::dv.:J'GPiI'J <br /> EH 23 032 (REVISED 11-1-92) Page 11 <br />