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SADUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME , <br /> IF D A� <br /> C <br /> 1 FACILITY ADDRESS SITE PHONE N with AREA CODE <br /> L <br /> I <br /> T CITY .- STATE ZIP CODE 0tIff TANKS <br /> Y �s va 1jer'f4 Y SI <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> A <br /> Pr' � � <br /> L <br /> I MAiLINO ADDRESS APPLICANT PHONE A WIT114REA CODE <br /> C f 3 ltlle Illee /C—X1 � <br /> A <br /> N CITY STATE ZIP CODE TY f APPLICATION <br /> T � Q �, �5 Cry CLOSU INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (prior to January 1, 1991) = $100.00 <br /> (or 100- o- A66- 1100 _ 9 Zoe <br /> V <br /> E TANK FEE _ %50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F N Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (auttipiy fee for <br /> C each year applicable) 15o 15o 366 36o /5v <br /> L STATE SURCHARGE = %56.00 each TANK (Due every 5 years) See California H S S Code, Section 25287 <br /> T 0 Tanks x 556.00 1986 through 1990 1991 through 1996 <br /> Y (enter anlaLrlt and year) � � ! 6 49 <br /> $ <br /> PERMANENT CLOSURE (Removal or Authorized Ctosure-in-Place) TANK I.D. ft(s) <br /> C rl"—c cee - re-r nn __- L--.- — L_..__ _'-'_ - .. $ t� �l � <br /> j <br /> MObE5TO BANK1140 COMPANY 90-373211211 Y <br /> Zoom F.C"K nv AVCNVe _ <br /> MOOGf[C C.ALIPOrt NIA 11190 <br /> r <br /> 3523 <br /> SEMCO <br /> EN;1NEOENtAL s <br /> CONTRACTOR <br /> 431 W. HAtCH FID. 12091 524 9653 <br /> MODESTO,CALIFORNIA 95351 <br /> DOLLARS % <br /> To THE ar `h br` b CHECK Ho. AM(5UA+ <br /> SEMCO $ <br /> i <br /> r <br /> / a <br /> OFFICE USE ONLY f Sry + fP Ls LLX/J (y <br /> »,�A.1K+..»ww11»0 Mw+0 xM IIN 111M0»M.1sffl lwv �`♦a�W6.�xu as esmv,•s/rr ee s<..a t st.<r xa ; s -s � Ir wr.<o e-n� M aw.is.ar,fw w.a.e ww».wr•ww su++r�»»M»A»M s. Xis11 <br /> CO " )I�Si CCbE 'A�10tiiiTRc+iu "CSIE C1C'`'�IGilSli""" RCV1"'AY E > diE WYMEE` <br /> » <br /> x <br /> »M»M>IV�AM»Y�»�»w10fMfM►3M,1%N»NM%MxP%f:ti'1;wabx:A:0:1.Ya.1M:v.F:[^:t4 t?:{i?:Y v6kMY5 ? J N? 6 M /.I C1:CRi.wlkwM iM»M »M NM�!]1M»MMlM 1�»►wM MM Aw�M iIMIW <br /> peal tier la,SAf oarmallamn�a sly%lc�x 7�A4vx m.7s)th.5 as7Hs".Yr>Ys.<:'E '.t?7>:.Y.^.".':Y:B.Y•.'„!':,..:.Y^..:.. -......s...,.- -.,,.,..:.:.,,:s>.'Y,.».Yf T'Sl.�,.1I,1.7` i".`.W,.`YI'lAl"�L1160.1Nif 1BU�J551�t1klF>�YAMt►bs AtNY�AR11 <br /> ru )'t n7t7 tvcv 17/7Rmni ft p,an >I1 0 <br />