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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICea I;7( <br /> a •' ' ENVIRONMENTAL HEALTH DIVISION _ <br /> U OUNO STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAME <br /> F1� '-x '4'� c�/�'F ITE Cc��rA�(A�tiA <br /> C SITE PHONE # with AREA CODE Z 732 <br /> LFACILITY ADDRESS E1TL�/7 IAU 1AAfe >�- r"'�34- <br /> 1 �Q2 E <br /> STATE ZIP CODE # of TANKS <br /> Y CITY/ /7A Y-Pn ) at SITE <br /> C-ft ! AppLICANT CONTACT NAME <br /> A APPLICANT/BILLING NAME <br /> I urLEC�Vc C'e> <br /> L APPLICANT PHONE # WITH/AREA CODE <br /> I MAILING ADDRESS O 209 --547- 24-"' <br /> C p,D , �ir:X 2L-1 L1.A� T.�4�1(cA✓An4 FLi <br /> A �]A E rt21P CODE TYPE of APPLICATION <br /> l d '(-5Z1�( CLOSURE, INSTALLATION, etc.-)C/L SARI FYE`� <br /> T G�Tcx Krc>ry <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> C5 <br /> T ANNUAL FACiL1TY FEE (Prior to January 1, 1991) $1 <br /> 00. <br /> I <br /> V $50.00/TANK <br /> (after January 1, 1991) <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) <br /> F T Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (mLtiply #_by fee for $ <br /> C each year applicable) <br /> L <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, section 2528 <br /> 1986 through 1990 1991 through 1996 <br /> T d Tanks__ X $56.00 S <br /> arra <br /> Y (enter Mt and year) <br /> PERMANENT CLOSURE (RemovaL or Authorized Ctosure-in-Place) TANK I.D. #(s) <br /> C # TANK(s) X $159.00 <br /> L CLOSURE FEE - S53.00 per hour (3 hours mininXm per <br /> TANK) �_ <br /> O <br /> S .m.. s..� ......:....r...........:..._. ...� . .. .,._. <br /> k11(EA AG j;k;1(VICk: BANK OF AMERICA <br /> CHECK NO. <br /> P.O. BOY 201059 LOS ANGELES MAIN OFFICE C (1 <br /> iUCKPOA, CA 95201 <br /> 525 SOUTH FLOWER STREET 4 2 50.DATE 1 C `.) <br /> LOS ANGELES,CALIFORNIA 90071 0 0 4 1 ' 'J 1 <br /> NETAMOUNT <br /> (.10k: HUNDRED F1F')'Y 141141" 1)ULLARS AND 00 CENT1' <br /> PAY TO THE ORDER OF NOT VALID FOR OVER$2,500.00 <br /> COUNTY OF LiAN JOALUIN <br /> E'UHLIC HEALTH :;ERVICES VOID AFTER MONTHS FROM ABOVE DATE <br /> 1 <br /> I <br /> ewe .,,o, ewc nnwm nua- -FnCLR-w an ACbCI VCJ DI <br /> VAIC ec6c:vcu i <br /> . .......... <br /> .................... . ................ <br /> •••.•• ••••••••••• IMIW IW)MM,n,�aM�MM,,,�WwfWaN,IMMv.WY„MI,wl1�M.�YMMMMMfWwlMl,tlbIFIYMf1��Miw,�,M <br /> ........Nm.D..,ams..:....r:asM....aiN.mNaw.x.aw m�N.,......N.,xr...«....Nsa...,.A.w.rr...rK..,.Nr..wN..m.>a+...............w.N....... <br /> Pace 11 <br /> EN 23 032 (REV 1/10/911 ft <br />