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r <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE VORKSHEE <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> FCliff Mc Bride <br /> A YDependable Precision Mfg. , Inc. <br /> C SITE PHONE 0 with AREA CODE <br /> I FACILITY ADDRESS (209)369-1055 <br /> L 1111 S. Stockton St. <br /> I STATE ZIP CODE I of TANKS <br /> T CITY Ca, 95240 at SITE 1 <br /> Y Lod J , <br /> A APPLICANT/'BILLING NAME APPLICANT CONTACT NAME <br /> P cliff MG Bride <br /> P Dependable Precision Mfg. , Inc. <br /> L APPLICANT PHONE R WITH AREA CODE <br /> I HAILING ADDRESS (209) 369-1055 <br /> C 1111 S. Stockton St. <br /> A STATE ZIP CODE TYPE of APPLICATION <br /> N CITY Ca, 95240 CLOSURE, INSTALLATION, etc. Removal <br /> T Lodi, <br /> �— TOTAL <br /> A 1986 1987 1989 1999 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1 941) 1100.00 <br /> 1 <br /> V 1170/TANK (after January 1, 1941} <br /> E TANK FEE 150.00/TANK (prior to January 1,1941) <br /> F 0Tanks = 148h 1987 1989 1499 1990 1991 1942 1493 1944 1995 1996 <br /> A (Intitiply M by fee for ! <br /> C each year eppticebte) <br /> 1 <br /> L STAT! SURCHARGE = 156.00 each TANK (Due every 5 years) See California H 1< S Code. Section 25287 <br /> I1991 through 1996 <br /> 1 0 Tanks x 156.00 1986 through 1940 <br /> r (enter Wro unt and year) 1 <br /> PFRMANENT CLOSURE (Removat or Authorized closure•in-Ptace) TANK I.D. N(s) <br /> C x 1154.DD = 1159.00 �L <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) ty TANK(s)_]_ <br /> THIP CHOCK IS IQfLIVER@U FOR PAVMCNT <br /> 12223 2 2 2 3 <br /> ON TeiR FOLLOWIrvB ACGf?V NTe. ."7L LJ 4/ G V1 <br /> GATE AMOUNT A I C I„I_`.�A RT AJ <br /> JIM THd1IPE, t)ISTRIOLIt011{Y1bF OUALItY PRCfbUCTS <br /> P.O. BOX 357 368-&175, 462-45581 <br /> 5 - -� 351 N. BECKMAN ROAD 90-845/12tt <br /> LOBI, CA 95241-0357 <br /> zc� PAY <br /> -- TO THE <br /> ORDER 0 <br /> ar, L OLLARS <br /> TOTAL OF INVOICES <br /> OISCOl7NT FI�RMEA & <br /> MERCHANTS <br /> TOTAL OEOUCTIONS BANK C�LI�`RRW, <br /> 131 x[sT RKL gaol..CA aetn0 <br /> AMOUNT OF CHECK <br /> <br /> 7 TOTAL DUE 1 159•00 <br /> r . <br /> OFFICE USE oNtr `1 ..... M' <br /> y. <br /> +w.,,,,,.,,,.,,,,,.,,,.„e.,,em.ee.ze.e.Ie»»wer•xr»w�..0»et•y.a. W <br /> rnm -mrmr "%mrrm ” <br /> a ,; ... s..� .q................ 1 "/ <br /> EN 7.3 032 (REV 1/10/911 ft Pace <br /> �f <br />