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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME <br /> T M FACILITY CONTACT NAME <br /> m�' <br /> E FACILITY ADDRES <br /> a n / SITE PHONE N with AREA CODE <br /> CITY <br /> A ` STATE ZIP CODE M of TANKS <br /> P at SITE <br /> P APPLICANT/BILLING NAME '? _ Ale <br /> L APPLICANT CONTACT NAME <br /> I G !/C/ <br /> C MAILING ADDRESS <br /> A APPLICANT PHONE N WITH AREA CODE <br /> N <br /> T CITY <br /> STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 1986 1987 1988 1989 1990 <br /> A <br /> C 5 <br /> T FACILITY PENALTY FEES ASSESSED (if Appticable) %%%X X%XX <br /> I 5 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) 2170/TANK (After January 1, 1991) <br /> E <br /> III Tanks 1986 1987 1988 1989 1990 1991 1992 1993 <br /> F (multiply k by fee for <br /> A each year applicable) <br /> C 5 <br /> I TANK PENALTY FEES ASSESSED xXx% XXXX 1994 1995 1996 <br /> L S <br /> I STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H & S Code, Section 25287 <br /> T <br /> Y A Tanks Z x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter anaunt and year) <br /> ECLOSURE <br /> SURE (Removal or Authorized Closure-in-Place) TANK I.D. N(s) <br /> 578.00/hour (3 hours minla AWTANK) 0 rANK(s) X 5234.00SURE (Plan Review T^- Z�B <br /> i <br /> LINVILLE N. WISECARVEp LIC. 20393075 9-92 <br /> P INSTALLATION M JANET WISECARVER LIC. 00006947 <br /> L REGINA COTHR LIC. E0277894 19 4 _ <br /> 0. , 1965 S. DRAIS RD.. 209-464-7740 <br /> N PLAN CHECK FE STOCKTON, CA 95205PAYTO <br /> a <br /> t <br /> ORDER OFF <br /> R REPAIR FEE (W <br /> E :il 2 J� _ ,_ �y .i i DOLLARS <br /> P TANK LINING R it r µ�yJ7 <br /> A t �' <br /> I TANK RETROFIT <br /> 8io ,log <br /> 1 <br /> R HEADQUARTERS <br /> PIPING REPAIR LH E_Miner Ave-smrer.n.CA 95Al <br /> MEMO <br /> M TRANSFER FEE .T <br /> I <br /> C CONSULTATION FEE = 578.00/hr SAMPLING INSPECTION FEE 578.00/hr S <br /> TOTAL DUE S Z Z O J <br /> FOR OFFICE USE ONLY <br /> —n-1, r r n nmmnmv mommmmmRmm!R�mmnn! <br /> mmmmax 1H III munm!mmm!m!mRi!iirmmmaamm!mmmm!ma.HEIRmanm!!mrr!imm!!mm <br /> SWEE�Rmt41:. COMPUTER <br /> 0 RI OD ,rauimmm!m!m!m 9 i.3!a !111!4!�!Im!!ILF:'�'Jlfmi!1!!ii!!iiliii!9i!fli!ii!!ii!!;!L:Lm;!fi!ii9iiiii!i!ImL .T:nm!!ha'dn!rp!m!i!J!r!!E!ii!i!�!::: :+: <br /> SWEEPS !! COMPUTER N LOC CODE DIST CODE AMOUNT RECEIVED CHECK N/CASX RECEIVED BY DATE RECEIVED i� m <br /> �5 52 &7(1417 V 3 2 Z r(9v 2p <br /> _.............. .. mR!!mR:!ame ,xm!: .MM m RHMI nmme!�xummm�wmm�� "'rrs�m�- •!o!!mmm!!!Mm. r <br /> :r::::e:-::::,- _!:!!_e:!!!!=_!=i._.!:ny:.s'T!mu!Is m-M1 i. ._rr::!m.1!!m; ._,.,_ <br /> Wi!Ii��:��. .mmrm.=m!me!!!m!Fi!!!!Eo,,:!!,!!!!;!!!!m!!! <br /> EH 23 032 (REVISED 11-1-92) ..^ Page 11 � ..i <br />