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~� SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM • FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> E <br /> I FACILITY AD S..' + �y�%L SITE PHONE 0 with AREA)��, <br /> 1 CITY ( „ STATE 21P CODE 0 of TANKS Of,� <br /> Y � � �(�` at SITE To <br /> A APPLICANT/BILLING NAME �P� G�� APPLICANT CONTACT NAME <br /> N-I�N �i1%�`7,�z�ll`7�O�!/ CT.6'L u�bvTLES <br /> I NAILING ADDRESS.-' \T AP ICANT PHONE 0 WITH ARE ODE <br /> _� ed 3 .3�9- 305 <br /> N CITY STATE E PPLICATION <br /> T �OO�� CLOSURE NSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 19871988 1989 1990 <br /> 1 ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I $ <br /> v <br /> E TANK FEE _ %50.00/IANK (prior to January 1,1991) %170/TANK (after January 1, 1991) <br /> F 0 Tanks = 1986 1987 1988 1989 1990 1991 1992 1 1993 1994 1995 1996 <br /> A (milt(ply I��lee Tor <br /> C each year eppl icebl e) $ <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California N d S Code, Section 25287 <br /> I <br /> 1 M Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> r (enter mountand year) <br /> It <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(s) <br /> C <br /> l CLOSURE FEE = S53.00 per hour (3 hours minla per TANK) 0 TANK(s),2� X $159.00 = f / <br /> EXPLANATION AMOUNT 90-103 <br /> 211 <br /> 2309 '00 = % <br /> CHECK <br /> f <br /> A/P DEBITRETENTION DISCOUNT RETENTION CHECK AMOUNT <br /> WITHHELD PAYABLE NUMBER <br /> s p <br /> Rj. 1 <br /> 9.00 = s <br /> _s <br /> 1lmrtars <br /> CA 85202 <br /> TOTAL DUE f <br /> OFFICE USE ONLY <br /> .-r <br /> -.....................ww....-...........�....1..........................C�....)......°... T'S. .. . ..... <br /> (...... <br /> L....1+..m...v.m...................�...A................ <br /> >........s..f..............A..a..o.l.w....>.�.....�..........w....w..w....lw....w....wawmww. <br /> :Sw0ww r . . ...wnwwwwow . ..wwww > I <br /> Pv Z3oM <br /> rwwwwwwwr w„wwwwwr..».,www..riwwrir' 91 iiVw <br /> +••^s.TM+xvAaawAawanalmpwrxeuraamaamxaxtnrr�xauwAwwrsnmswwlawAnnwaAwwAwwwzxrr--�»aexmaawwxwwaeaawawarwswwrswlm <br /> Fw 71 057 IREV 4/8/911 it Paoe 11 <br />