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i <br /> AI ; SAM JOAUUIY CO1111TY PUBLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH DIVSION <br /> UIDERGROM STORAGE TANK PROGRAM - FEE 1iURKSHFET <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAME <br /> T <br /> T SITE PH E M with AREA CODE <br /> FACILITY ADDRESS ~ Z <br /> 95�- <br /> S &JC ) STATE ZIP CODE 0 of TANKS / } <br /> CITY 4 rA F— at SITE /it (SOD <br /> A �i Ai'PLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAMELE <br /> 1 APPLICANT PHONE- 0-STT AREA <br /> COD <br /> C ILING ADDRESS [� <br /> A STATE ZIP CODE TYPE of APPLICATION 71fWk <br /> N <br /> T CITY <br /> -,a �_,C) (Closure, Installation, etc. <br /> TOTAL <br /> 1966 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE ('Prior to January 1, <br /> 1991) 5100.00 $ <br /> AS <br /> C Applicable) <br /> %%%% %%%% <br /> T FACILITY PENALTY FEES ASSESSED (If App 1170/1ANK (After January 1, 1991) <br /> I <br /> V TANK FEE 150.00/TANK [Prior to January 1.1991) <br /> E 1986 1987 1988 1.989 1990 1991 1942 1993 1994 1995 1996 <br /> M Tanks <br /> F (multiply N by fee for <br /> A each year applicable) 1 <br /> C <br /> 1 TANK PENALTY FEES ASSESSED xxxx xxxx <br /> L <br /> 1 STATE SURCHARGE - $56.00 each TANK (Due every 5 years) See Cellfornle H 199ICodrougsection 25267 <br /> 11966 through 1990 <br /> T N Tanks x 556.00 S <br /> (Enter amount and year) <br /> TANK I.D. S(!) <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) x 1234.Op S G <br /> L 0 TANK(*)_�� ' <br /> 0 CLOSURE FEE ■ 578.00/hour (3 hours minimum/TANK) - <br /> _ 34058 <br /> FROELIGER MACHINE TOOL CO. <br /> 3023 MYRTLE STREET 948-2888 <br /> STOCKTON, CA 95205 90-10811211 <br /> 19�. <br /> PAY �'IU 4Z�ce,. <br /> TO THE <br /> ORDER OF--- <br /> _DOLLARS <br /> UNION SAFE <br /> DEPOSIT BANK <br /> 377 E.MaM 3t..Stockton,CA 96707 <br /> FOR-6A-S; 1e- Grri�I�VLr41+i - A �.r: <br /> I <br /> 15 <br /> TOTAL DUE S <br /> TE:Q] <br /> -4 OFFICE USE ONL�r 01 <br /> "M t� to DATE RECEIVED <br /> i!77 !Im ° ! <br /> "M!!m1!r!In i 18 <br /> SWEEPS � COMPUTER � LDC CODE DISC CODE AMOUNT RECEIVED H /CASH ��RECEIVED 8Y J//31`7 <br /> rli 3 N v S <br /> r, qp� � lu <br /> omni!:!. 319s!nnl� § I� .IWRI WgIlmi. t <br /> r,im nl!. 4i. 4f 3..L. <br /> Page 11 <br />