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S <br />I <br />T <br />A <br />P <br />P <br />L <br />I <br />C <br />A <br />N <br />T <br />SAN JOAQUIN MO&MLIC NEALTN SERVICES - MIRONMENTAL W-ALOIVSION <br />UNDERGROUND STORAGE TANK PROGRA14 - FEE WORKS"FET <br />FACILITY SITE MAKE <br />FACILITY CONTACT NAME <br />FACILITY ADDRESS 1-( SBS L-:,,, 4e- 1-v 1P, <br />SITE PHONE 0 with AREA CODE <br />CITY <br />STATE <br />ZIP CODE TANKS <br />T FACILITY <br />PENALTY FEES ASSESSED (if Applicable) <br />=0101? <br />at SITE <br />APPLICANT/BILLING NAME,----) APPLICANT CONTACT NAME <br />elrm' <br />MAILING ADDRESS APPLICANT PRO" N WITH AREA CODE <br />SAMPLING INSPECTION FEE v $78.00/hr <br />CITY- <br />ST TE <br />l ZIP CODE <br />j®5/ <br />TYPE Of APPLICATION <br />(Closure, (Closure, Instattation, <br />I <br />, <br />etc.) <br />ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br />C <br />TRANSFER FEE a 120.00 <br />UNAUTHORIZED RELEASE EVALUATION n 978.00/hr <br />T FACILITY <br />PENALTY FEES ASSESSED (if Applicable) <br />(Xxx 1 <br />XXX7X <br />SAMPLING INSPECTION FEE v $78.00/hr <br />I <br />V TANK FEE <br />e 150.00/TANK <br />(Prior to January 1,1991) <br />1170/TANK (After January 1, 1991) <br />E <br />0 tanks.= <br />F (multiply <br />F by fee for <br />1996 <br />1987 <br />1988 <br />1989 <br />1990 <br />1991 <br />1992 <br />1993 <br />1994 <br />1995 <br />1996 <br />A each year <br />applicable) <br />C <br />I TANK ---- <br />L <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br />N <br />TRANSFER FEE a 120.00 <br />UNAUTHORIZED RELEASE EVALUATION n 978.00/hr <br />C <br />CONSULTATION FEE - t78.00/hr <br />SAMPLING INSPECTION FEE v $78.00/hr <br />FOR OFFICE USE ONLY <br />91 <br />MUMI TO R I N N 11"I ff. 0 =01 M I <br />.1 wiefiftw9miffl- M <br />COMP "M <br />SWEEPS LITER N LOC CODE DIST CODE AMOUNT RECEIVED <br />Ell 23 032 (REVISED 11-1-92) Page 11 <br />TOTAL DUE Lt-- zz 7o,cvl <br />RECEIVED BY DATE RECEIVED <br />. ... ........ <br />ol® � <br />