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C-2 S* JOAQUIN LOCAL HEALTH STRICT <br />_ _ _ UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br />F FACILITY/SITE NAME <br />IA FACILITY CONTACT NAME - <br />C Tre house Nurser _ <br />L STREET ADDRESS �- SITE PHONE # WITH AREA Cant <br />I 8980 Ey E. Hwy 12 _ 20 -� —1922 <br />.._.._._._ .. . <br />Y CITY STATE ZIP CODE # of Tanks <br />Victor, Ca. 9-5253 �5 at Site <br />A APPLICANT/BILLING NAME�r —�~ APPLICANT CONTACT NAME <br />FHerbst Engineering, Tnc. <br />L Eduard G. Herbst <br />_.__._. _`._.._....__._,_. _._ _ _ __._____ _.._.__ _ _ __.�...__._...___._ _ _ <br />I MAILING ADDRESS APPLICANT PHONE # WITH AREA Cans <br />A <br />P.O <br />Box 22-504—-�q�- (916)422-2628 <br />N CITY SATE �T8 <br />OE TYPE of APPLICATIONT Sacramento, A 9. 22 CIOONRE, IN9TAl LAT IONx ITG.Remo�%r�l <br />FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br />A............___. _ _.....—..._._..._..__,�_ <br />1986 1987 1988 ...-1985 <br />E TANK FEE = 150.00 each TANK <br />..__..._......._............ <br />F # Tanks _ x $50,00 1986 1987 1988 1983 <br />A (NultipTy Fby tee for <br />+' each year applicable) <br />L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25281 for applicability) <br />T I Tanks x $56.00 1986 1981 _ 1988 <br />Y (enter iioui►t and year) <br />.............. <br />+' PERMANENT CLOSURE (Removal or Closure -in-place) <br />L <br />F# Tanks 4 j <br />x *30.00 ; 360.00 <br />HERBST ENGINEERING, INC. <br />422-2629 OR 422-2628 <br />5980 - 24TH STREET <br />SACRAMENTO, CA 95822 <br />PAY <br />70 THEORIT� <br />f - <br />OF <br />BKP•,.■ THE BANK OF CALIFORNIA <br />X11. Sacramento Regional O1fire <br />770 L Street, Suite 1400 <br />Sacramento, California 85814 <br />OFFICE USE ONLY <br />7254 <br />�� 11-1/1210 <br />Y9 <br />$.; <br />_ I_AR5 <br />TOTAL DUE <br />.... ........_.....,.__.,M„,„,. ..w,... �nx�xu��nlxINmILrN7i.11N�I <br />SWEEPS # COMP # LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD HEC /CASH RGVD BY DATE P,ECE1'VED PERMIT # <br />....... _.... <br />.._..... <br />it lil�� Ei �r �u! !!Il!l it l!!!lIIIlldill,'llhlllllil llil�l,lllll llll�IfII IC'IflPl lllllgllnBgrllriln111 IPi uuinimnnnnNNnnnnN inwn im l�lm�0. .„ . , ... I j L1_. _.. ! ` ! 'M-9 b �7/ 1 <br />