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+ SAN JOAUUIN OTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL 0TH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACILITY SITE NAME FACILITY CONTACT NAME <br /> ' „Tlit r.l:r. -Isi„�rl� t;ill h(-: ti <br /> T <br /> E FACILITY ADDRESS SITE PHONE # with AREA CODE <br /> I <br /> i f`ILT fW Alt.,ft l',a_.0 'J•-c) <br /> CITY, STATE ZIP CODE # of TANKS <br /> A I •t�l. -I, l_;I� CA r] at SITE .3 <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> 1 <br /> C MAILING ADDRESS x APPLICANT PHONE # WITH AREA CODE <br /> N <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> ��•,`:� (Closure,Qnstallat ions eLc".) - <br /> TOTAL <br /> 1986 1987 1988 1989 1990 ICiG L•(• <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5100.00 <br /> A XXXX XXXX XXXX XXXX X%X% S XXXXXXXXXX%X% <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Applicable) XXXX XXXX XXXX XXXX %XXX S X%XXX%XXXXXXX <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) 5170/TANK (After January 1, 1991) <br /> E <br /> # Tanks = _i 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 Ind"O35a3$ <br /> F (multiply # by fee for <br /> A each year applicable) XXXX XXXX XXXX XXX% XXXXS C�Lj <br />