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SAM JOAQUIY CY PUBLIC HEALTH SERVICES IUwwaAlp STORAGE TANK ENVIRONMENTAL FEEWON' X DIYSION <br /> 5 FACILITY SITE NAME EEE 1A1RKSIYF40 <br /> 7i—� Ur•-�-fPa�' FACILITY CONTACT NAME <br /> Fj FACILITY ADDRESS <br /> X1 0 / Il - 6>,qk-- ST. SITE PHONE # With AREA CODE <br /> CITY <br /> 7 <br /> P p - STATE ZIP CODE # o} TANKS !" <br /> P APPLICANT/BILLING NAME `""r r �SZ y[7 et SITE <br /> I /J�P.Qy0�,�'GG APPLICANT CONTACT NAME <br /> CMAILING ADDRESS <br /> M �� C(/ . S� .!.-T.^I �,( In APPLICAN <br /> i CITY PHONE # WITH AREA CODE <br /> r �Zry' 02 <br /> FszCS O 5T 7E ZIP CODE O <br /> TYPE of APPLICATION <br /> 937oGi (Closure, Installation, eta.) <br /> ANNUAL FACILITY TOTAL <br /> A E (Prior to January 1, 1991) _ 5100,00 1986 1987 1988 1989 1990 <br /> C <br /> T FACILITY PENALTY FEES ASSE ED (1 A XXXX XXXX /Do too /pV Z 30� <br /> 1 550.00/TANK le <br /> V TANK FEE xxxx xxxx uv o= loJ 5 'R� <br /> E J <br /> # Tanks rio J ry 1 1) <br /> / 1 <br /> 5170/TANK (After Jarwary 1, 1991) p p <br /> F (multiPly #Nby fee for 1986 1987 1988 1989 1990 1991 1992 1993 1994 <br /> A each year applicable) 1995 1996 <br /> C XXXX XXXX /j O Sb s[7 <br /> I TANK PENALTY FEES ASSESSED %X%% %XXX p J 7cv 17o 17p 11 !�O <br /> L 5 �i7 SC7 / 7J /7V )70 bb <br /> 1 STATE SURCHARGE • 556.00 each TANK (Due every 5 years) See California N 6 S Code, 11 U <br /> T Section 25287 <br /> I AF � x t56.00 <br /> (Enter amount and year) 1988 through 1990 <br /> 1991 through 1996 <br /> Pte( P 9 <br /> C PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Ptace) <br /> L TANK I.D. #(a) <br /> 0 CLOSURE FEE = 579.00/hour (3 hoursmin imun/TANK) <br /> S # TANK(,)_L X 11234,00 pe 5 <br /> U TEMPI <br /> R (tel /� , I TANK I.C. #(s) <br /> E TEMPORARI VVV <br /> # TANKU)__ X 5234.00 = 11 <br /> P INSTAllA1 !�� <br /> L tions) TANK I.D. #(s) <br /> A <br /> N PLAN CHEI <br /> = 5624.00 minimus S <br /> LA <br /> FI <br /> ANK I.D. #(s)) # TANK(a) K 11234,D0I <br /> ITT) = 11234-00 mini"' <br /> = $234.00 minflunp 11 <br /> M TRANSFER <br /> VALUATION = 1178.00/hr <br /> I 5 <br /> S <br /> C CONSULTATION FEE = 5/0.uu/nr I aanru su inarwiwn rcE a <br /> (78,00/hr 2 <br /> ICJ '-7 <br /> D <br /> FOR OFFICE USE ONLY TOTAL DUE $ <br /> iVEEPS # COMPUTER # LOC CODE DIST CODE AMQINT RECEIVED CHECK #/CASH RECEIVED DT <br /> DATE RECEIVED <br /> ..:,. _ - ��-is�'�:;u-r .-*"m: <br /> E)1 23 032 (REVISED 6-21-93) <br /> • Page 11 <br />