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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br />ENVIRONMENTAL HEALTH DIVISION <br />UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br />F FACILITY SITE NAME FACILITY CONTACT NAME <br />Gen <br />I FACT ADDRESS SI U PHONE 0 with AREA CODE <br />3 �Gt.0 t V , 583 - ?. <br />T CIT STATE ZIP CODE at SITE <br />8 of TANKS <br />Y <br />A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br />P g► l Iced <br />P <br />L <br />I MAILING ADDRESS LICANT PHONE III VITUI AREA CODE <br />iA <br />4 Qsl -30 <br />N CITY STATE ZIP CODE TYPE of APPLICATION <br />T CLOSURE, INSTALLATION, ate. <br />A TOTAL <br />C 1986 1987 1988 1989 1990 <br />T ANNUAL FACILITY FEE (Prior to January 1, 1991) ■ =100.00 <br />I f <br />V <br />E i TANK FEE ■ $50.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br />F B Tonka■ 1986 1987 1988 1989 1990 1991. 1992 1943 1994 1995 1996 <br />A (multiply fee for <br />$ <br />C each year applicable) <br />I <br />L STATE SURCHARGE a $56.00 each TANK (Due every 5 years) See California H i S Code, Section 25287 <br />I <br />T 0 Tanks x $56.00 1986 through 1990 1991 through 1996 <br />Y (enter anount and year) <br />C <br />PERMANENT CLOSURE (Removal or Authorized Closure -in -Place) TANK I.D. aY(s) D �Ilfl <br />LCLOSURE FEE ■ <br />0 $53.00 per hour (3 hours (minimum par TANK) 0 TANK(*) --I_ X $159.00 ■ ! S� a �� V <br />-Y TH19 CHEM IA OELIV WD FOIE 10ilMgNT'�- <br />ON THE FOLI-OWMO ACCOUNTA <br />V <br />NxsrB�rclox�,� i 18.8 6 <br />- ca <br />— -- 5837 N. PERSHING AVE., SUITE A-3 9'51-9304 <br />$ FOCI(T ON, CA 95207 <br />-- .. <br />"' �,.80101I1t11 <br />— -- PAY <br />TOTAL TOTHE ; <br />ORDER OF-, <br />DISCOUNT+'. i ` wK- • �Ow. <br />AMOUNT OFI <br />L_. OLLARS <br />UNION SAFE a3o7 <br />DEPOSIT BANK <br />�. <br />6666 N. Pamhhp AV*., Stocktm GA 06101 <br />III 1 iB86He ' 1:121`101013 2i:4"b' bqo 7 SII'0 2 <br />TOTAL DUE t <br />OFFICE UN ONLY <br />Z 1.- <br />FMNXWll SWNX <br />n 23 w CNEV 4/l11011 ft .a. <br />