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SA JOAQUIN LOCAL HEALTH EO TRICT <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />Fh�__FACILITY/SITE <br />..__......________ NAME <br />NAME � � <br />C <br />FACILITY CONTACT NAME <br />I <br />e5e s SGT ` Z!42s°l <br />C <br />L <br />STREET ADDRESS^ ^- - <br />1987 <br />SITE PHONE I1 aIT" ARCA CODE <br />I_ <br />1 <br />T <br />--- <br />CITY <br />STATE ZIP <br />CODE II of Tanks IM Ijr <br />GL <br />I-4 <br />at .Site VJ <br />P <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />JAN 25 19go <br />TANK FEE : $50,00 each <br />TANK <br />F <br />A <br />C <br />A Tanks x 650,00 <br />(sultipTy't-by fee for <br />each year applicable) <br />P <br />1986 <br />1987 1988 <br />_ <br />I <br />MAILING ADDRESS <br />I <br />L <br />APPLICANT PHONE 1 "IT" ARES iENTAL HEALT6 <br />�sT � <br />N <br />CITY <br />STATE ZIP CODE <br />TYPE of APPLICATION <br />CLOSURE, INSTALLATION, ETC. <br />T <br />W <br />m=T$100.00 <br />TOTAL <br />FACILITY FEE each SITE ADDRESS per YEAR <br />C <br />1986 <br />1987 <br />1988 <br />1989 <br />1 <br />E <br />TANK FEE : $50,00 each <br />TANK <br />F <br />A <br />C <br />A Tanks x 650,00 <br />(sultipTy't-by fee for <br />each year applicable) <br />1986 <br />1987 1988 <br />1989 <br />/SO vo <br />$ <br />I <br />L <br />STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for applicability) <br />I. <br />T <br />Y <br />I Tanks -3 x $56.00 <br />(enter mount and year) <br />- <br />�. 1986 1987 1988 1983 Q <br />OFFICE USE ONLY <br />SWEEPS $_......I.....COMP $ ILOC CODEIDIST COD <br />b' Ci3Nr-3c,2 3 <br />AMOUNT DUE I AMOUNT RCVD <br />..... .... ._......__.._._._.. <br />(ru 31 �,Gv 1 L/19D <br />TOTAL DUE <br />/CASH I RCVD BY I DATE P,ECEIVED I PERMIT <br />i-d5- <br />