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-..camWNU STORAGE TANK IOC.- FEE IX)RKSHEET <br /> S FACILITY SITE NAME <br /> T0 FACILITY CDIIiAI J1E <br /> E FACILITY ADDRESS <br /> .5 -jr—B Z-r4 }'p <br /> SITE PHONE # with AREA CODE <br /> s La1� <br /> clrr JIM- 3 82 y I <br /> A 1 STATE ZIP CODE # of TANKS <br /> P at SITE <br /> P APPLICANT/BILLING NAME <br /> L -t :n APPLICANT CONTACT NAME <br /> C "AILING ADDRESS t4 (. G r <br /> A APPLICANT P14CNE # WITH AREA CODE <br /> " r 11,-372— Iq 5 <br /> T Y CIT <br /> 1T STATE ZIP CODE TYPE of APPLICATION <br /> W 11 QS (Closure, Installation, etc.) <br /> TOTAL <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 1986 1987 1988 1989 nF; <br /> A CT FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX <br /> I <br /> V TANK FEE _ 150.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = __I__. 1986 1987 1988 1989 1990 1991 1992 1993 1994 195 1996 <br /> F (multiply # by fee far <br /> C each year applicabte) O <br /> f <br /> ITANK PENALTY FEES ASSESSED XXXX XXX% $ N <br /> L <br /> -11 <br /> 1 STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H i S Code, Section 25287 <br /> T <br /> Y # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) //-- <br /> c2 49 Is La <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK t.O. #(s) <br /> L <br /> 0 CLOSURE FEE = S78.00/hour (3 hours miniaxWTANK) # TANK(S)_ X $234.00 = f <br /> S <br /> U TEMPORARY CLOSURE (Plan Review b inspections) TANK I.D. #(s) <br /> R <br /> E TEMPORARY CLOSURE FEE • $78.00/hour (3 hours mininRWFACILITY) • S234.00 miniaAAn $ N <br /> P I INSTALLATION PLAN CHECK (Plan Review b Construction Inspections) TANK I.D. #(s) <br /> I <br /> FILCHER CONSTRUCTION, INC. ' 1807 <br /> $ to <br /> SERVICE STATIONS COMMERCIAL <br /> LIC. 177928 <br /> 4061 S PORT BLVD. 916-372-1985 / ( /»� g0- <br /> = f <br /> PAY TO THE /J,/y�J� //7JQp tr-c'r 1 �' <br /> f{-v_T-w ARS $ J <br /> SACRAMENTO FIRST <br /> s � / p <br /> NATIONAL BANK <br /> 915 L Sveeltr.Sacram/e�nm`,CA 95B11t)-1 t. � /� <br /> Ail A11)_I(��c� I 1-kF.I`t� JT J�14t Tl� 1. 4.�-4_L� $ N �� <br /> )TAL DUE f g <br /> �.��.�+�.wwwwwxwwiw«awl}aw�rpa�.wrf.�wF�wF.��.{wa�rr�_y�—ay—a�wy/r/�r�awF wrlw�ra�w{w■/a�i M�;-as�l�w.yfw��w,��a�w[Aa�wFww�wwwwr->.r�wAtr�awa�wai trFwAwwwww <br /> • »��$�� �� LU, lW UIS�LIUG /1MU1N1 !tilt l\�!U lXtf lC R/111511 Rtl.t1V��! � U111t Ntl.G l`�l Awyll <br /> Ca $ a <br /> s <br /> w'ar�i 1�°`s�wse�rn:r<aiaawrtir�aiwwsaiAria�llrssislwAisiwaasoAwA`wwsslwnairawaaiAiwnwarAinai+wrsais4eaisAMw�iiswwiaAiwwwsAsswwrsa <br /> EN 23 032 (REVISED 3-1-931 <br />