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/ <br /> / SAN JCACUIN COUNTY PUBLIC HEALTH SERVICE. <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGRQINO STORAGE TANK PROGRAM - FEE VCRKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> AG- <br /> C <br /> 1 FACILITY ADDRESS SITE PHONE S with AREA CODE <br /> L ?/ O/ G- Cl r1u [J v - 9 /v7 <br /> I <br /> T CITY STATE21P CODE Al of TALARS <br /> T $ taat SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P _WT Or a <br /> L <br /> 1 NAILING ADDRESS APPLICANT PHONE P WITH AREA CODE <br /> C <br /> A <br /> 4 CITY STATE ZIP CCOE TTPE of APPLICATION <br /> T CLCST.RE, INSTALLATICII, etc. <br /> TOTAL <br /> A Pon <br /> C 1986 1987 1988 19N0 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) • $700.00 _ <br /> f C) <br /> %ar /oma O b O .—. <br /> TANK FEE 550.70/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> 0 Tanks • _l, 1986 1967 1988 7989 1990 1991 1992 1993 1994 1995 1996 <br /> A (nultipty s by fee for It <br /> C each year applicable) ,SD TO 7 !OJ Awpiw YJ -- <br /> I <br /> L STATE SURCHARGE • $56.00 each TANK (Due every S yearn) See Cstilbrnie N S S Code, Section 25287 <br /> T / Tanks / A S56.00 1986 through 1990 1991 through 1996 <br /> T (enter an■ant and year) <br /> PERMANENT CLOSURE (Re at or Authorized Closure-in-Place) TANK 1.0. s(a) <br /> C <br /> L CLOSURE FEE $53.00 per hour (3 hours minia■Ae per TANK) 0 TANK(s)— K T39.00 <br /> - - 4364 <br /> LOWELL RATHE <br /> I MOBILE HOMES, INC. <br /> 2101 E. CHARTER WAY 948-1077 <br /> STOCKTON, CA 95205 90-108/1211 <br /> TO <br /> TOT <br /> e THE Q•/�j I , �'� <br /> 06L-ZARS <br /> UNION SAFE <br /> DEPOSIT BANK <br /> l amNEI Dor,Uo st So ron,CA NI <br /> IP [; <br /> TOTAL DUE S /&�9 d OB <br /> OFFICE USE ONLY <br /> :`r$�c,r✓}S'�' ±!v-T7T1 -mmolmd" /wa frarmair <br /> ■ <br /> "S. �'� ��r�>rr01' wG�•TriiC�ii., "•"'G:CSS� A7�Fii�•o��rr.�r•r;�+� <br /> �■■al■�S��wai/�■w�■•■■a�/lalae. �eaallle■m�aa�alaaaailm/e�amraa�/a/a>s1 ����ra�rrel•l ae�rar,rr�rr <br /> EN 23 032 (REV A/"lI it Oeee 17 <br />