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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> - - FACILITY CONTACT NAME <br /> CITY SITE NAME <br /> —._� - �-\ SITE PHONE # with AREA CODE <br /> FACILITY ADDRESS <br /> (�C% of TANKS <br /> i --3 - STATE ZIP CODE rr <br /> -- <br /> E CITY at SITE ( ( ( (". At ( <br /> APPLICANT CONTACT NAME <br /> A JAPPt1CANT/BILLING NAME <br /> (( �� <br /> P L_ �" i ", k' <br /> �. APPLICANT PHONE # WITH AREA CODE <br /> I Il1Nr1 fDRESS <br /> C TYPE of APPLICATION r) <br /> A STATE ZIP CODE {\ �, r <br /> [� CLOSURE, INSTALLATION, etc. ` �� iti <br /> � CIC C��r11.�' �J�{`' <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> CS <br /> F ANNUAL FACILITY FEE (Prior to January 1, 1991) c $100-00 <br /> 11991) <br /> V (prior to January 1,1941) 5170/TANK (after January 1e <br /> E IANK FEE 5 550.00/TANK <br /> 1986 1987 1988 1989 1994 1991 1992 1993 1994 1995 1996 <br /> F `a Tanks = $ <br /> A (multiply # by fee for <br /> C each year al�plica6Le) <br /> 1 _ ���—X5600 each TANK (Due every 5 years) See California H b S [ode, Section 25287 <br /> L STALE SURCIIARGE = 1991 through 1998 <br /> B through 1990 <br /> T N Tanks _ x 556.00 S <br /> Y (enter amloant and year) _ <br /> TANK I.D. if(s) <br /> PERMANENT CLOSURE (Removal. or Authorized CLosure-in-Ptace) r Q <br /> CLCLO�URE <br /> 5159.00 FEE = $53.00 per hour (3 hours minim un per TANK) <br /> n <br /> BANK OF 5TOCKTON <br /> <br /> CALIFORNIA CONTRACTOR LICENSE; 10 SA 29151 <br /> 600-820 N.UNION 5T., STOCKTON, CALIF. 95203 <br /> p.o, 6OX SOS STOCKTON,CALIF. 9520I-050B <br /> PHONE 209464-8333 -- <br /> `� DOLLARS s <br /> PATE <br /> CHFCK NO. <br /> _ ��LpR7 ceNTs <br /> vc f�ti�l. jjl�trlt S-5-`? 1 <br /> '2-9% 51 <br /> THE <br /> Sar► �or,L ^- `1 —� �- <br /> OF <br /> gTC)CKTCIN SERVICE STATION ECIUIP.CO.,Ilu E <br /> <br /> s <br /> tm <br /> Y.Y�a 7Yew w.�,Y.CYw,13YYW Yr`ww»�DoqortMY'ee.srw FYlonrwwYIrM�YiOFFICE USE 014LY e! U� rEo�rl�Yeww rl�ow�oiw Mww Yrw wI«Cner lrww YrwI»»lr»er liar waw Ylrr wow arrr avxr�l.w rs,o-1 xd° <br /> Y'i»»ai <br /> --- - <br /> UC) \S1 <br /> !.� ....A............. ......;;9AW ...TrT <br /> ....... "'r°n�iir m"waaa►�laia�tfrrataroeaaaorrxx�ae�� <br /> J <br /> as..,. ................ <br /> "W•.•.••.... <br /> •... xw wYw x�wowYo:O law»Yew 1N►1reeM urr ilea»wr 1Rwrxm <br /> Ilrlrr Iver liar»law YenwYver yYe Yo- <br /> W MM 1cNYe.w["LfYva Y>:�IrF Yo>ea YIPr>b YYr RM IerN!FM YttaOP NN}y..:.'l>oie <br /> lrw <br /> ax;2LY Ei;X�-';;.t=X'':tll 2hk'x X1Y7t6 i 4;It AYIIY':1X 33i2K'k1%'LQTY.'Xa1 AtY>C2UK�lY%f?k2Y zGi',1'd5K 10.Y}(�����Yi�IMS�l4�SK��l1111�lYtll <br /> Pao! 11 <br /> EH 23 <br /> 032 (REV 1110011 ft 0 <br />