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•JOAOUIN COUNTY PUBLIC HEALTH SERVICES • <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNOERGROUNO STORAGE TANK PROGRAM ' FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> CILITY SITE NAME <br /> C SITE <br /> PHONE x with AA CODE �( <br /> i FACILITY ApOR S <br /> L <br /> 1 STATE ZIP CODE 9 of TANKS .� <br /> T CITYS at SITE <br /> Y \ \ <br /> APPLICANT CONTACT NAME <br /> A APPLICANTIBILLIN NAME <br /> P <br /> P - <br /> L _ APPLICANT PHONE 9 WITH AREA CODE <br /> 1 NAILING ADDRESS <br /> C <br /> A STATE 2IP CCOE TYPE of APPLICATION <br /> N CITY CLOSURE, INSTALLATION, etc. <br /> I <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> Cf <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100-00 <br /> t2170/TANK (after January 1, 1991) <br /> V 550.00/TANK (prior to January 1,1991) <br /> E TANK FEE <br /> F $ Tanks • __ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1999 1996 <br /> A (aultiply X by fee for $ <br /> C each year applicable) <br /> 1 <br /> California H 2 S Code, Section 2528 <br /> L STATE SURCHARGE • 556.00 each TANK (Due every 5 years) See <br /> I 1986 through 1990 1991 through 1996 <br /> T Y Tank a__ x $56.00 1 <br /> Y (enter arrant and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-In-Place) TANK I.D. 1(s) UG <br /> C r TANK) Y TAHK(s __ K $159.00 <br /> L CLOSURE FEE • $53.00 per hour (i hours minlaxza pe _ _ . <br /> YAMADA PROS. INC. 1168 <br /> 15400 S. TRACY (j LY 482-4027 <br /> STO <br /> - STOCKTON, CA 05206 / <br /> 11-36/1210 <br /> PAYJJ �/� <br /> _v <br /> TO THE }� -.—J. $iCVNI 4/ <br /> ORDER OF 1 - - ' <br /> f[lvrtz,_� � .. ---DOLLARS <br /> Plank o Afnerlco" <br /> Cl.r -Wu SWEh 0588 <br /> PD.Bo,840 <br /> ewdd^GA 95201 - <br /> FOR <br /> _. ._.FEE af..53-.00/hr <br /> C FEE • 153.00/hr FEE • $53.00/hr <br /> TOTAL DUE �U <br /> OFFICE USE ONLY ____..__......................... .�O <br /> mrm <br /> a•••�,`��f�'A 111 • — / /„ 7 - / ..a <br /> ............ ...... . _.......... .. .....t ...r n,i:Y4r'1I �11r=mw <br /> e_.._..__.._.... .................._.... ..��.—�.... a�i(awwaw anal <br /> ....�.•—,•�•—•••�•�•, "Nmw rsaYawars�w aM allow <br /> wsawrwnrar�aa r,tw.ww ., pada 11 <br /> EN 23 032 (REV 1/10/911 ft <br /> wumr NfaMT,fff teMeH r�� <br />