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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICE <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ,c1TY SITE NAME FACILITY CONTACT NAME <br /> L cry eFo20 A��r �2f7�Qr�t Gs 0TE,2 ��y A//GG�2 <br /> Fo0 <br /> i1 FACILITY ADDRESS SITE PH ME 0 with AREA CGDE <br /> L 200/ .U, 2�Y <br /> l — . ? - 32os <br /> T CITY TSPT 'TE ZIP CODE if of TANKS <br /> Y KE 9/eD 9523 at SITE 2 <br /> A APPLICANT/BILLING NAME APPLICAN( CONTACT NAME <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE N WITH AREA CODE <br /> C 4�3/ �, Ilk 7r--d �'dsfD U? sz y6S3 <br /> A <br /> T CITY mn6)&Sr� 64 ZIP CODE�5�/ TYPE of APPLICATION ��1Q�/�(_ <br /> /,�o' (�{ CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) ■ $100.00 <br /> I i <br /> V <br /> E TANK FEE ■ S50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F N Tanks 1986 1987 1988 1989 1990 1991 11992 11993 1994 1995 1996 <br /> A (multiply M by fee for <br /> C each year applicable) $ <br /> 1 <br /> L STATE SURCHARGE ■ $56.00 each TANK (Due every 5 years) See California H i S Code, Section 25287 <br /> 1 - <br /> Y ( g MODgBTO BANKING COMPANY 90.3732/1211 <br /> ROCS NCH■NR• AV■NU• <br /> MpC■11Tu.CA41r011N1A.*i 9 <br /> P SFMC0 4857 <br /> C 01%N6RA�, ILNOINQi RIN4 & 1[NVIRON41CNTAL Co NTRACTon <br /> L C 431 W. HATCH RD. (208) 624-9653 <br /> 0 MODESTO,CALIFORNIA 86351 <br /> S . <br /> U T- <br /> IETPAY y� -,.� DOLS � � CTS DOLLARS— � <br /> TO THR ORPUR OF DATF CHUCK NO. AMOUNT <br /> P P #d` <br /> L mom, <br /> A <br /> N PI Swco <br /> VP 1: L2 ; 1, 3732811: 002-01323 ;1 <br /> M CONSULTATIONS UNAUTHORIZED RELEASE EVALUATION SAMPLING INSPECTION <br /> I <br /> S <br /> C f19 $53.00/hr FEE ■ $53.00/hr FeE ■ S 53.00/hr <br /> TOTAL DUE $ 3�8,OD <br /> OFFICE USE ONLY <br /> I1..,...,....sw,.�...I.1 )�..a..11.:lR4. l�..pr�lp��Rr..r,..rRw R�»pIR�.I�Rr.Ip..�.gRF�..,OY.,FO..l...1...l..K.Nµ.�.,.� �.p«py»�».. )...y1.�.)�RrKs.,.»Rp1R�.c I�R1.c MO...I....»A«..mm"m amw,.»»w..,...,...G..�,r«�.�R...R»,...,....,.»n.. <br /> �IasSAV <br /> V ii UMi' R LUI U1�1 LU/t ��LW ll1t� A5H IftLt� -i t rm- <br /> ......................... ........................ .................... ........................ .s.. ..1.. ............. ..`.r S ....... .... {`(� .......... ....... .. . 5... �` 1 .....Y <br /> lM-Iw�RwAIw�IMMlR�1��lA�hAIMR�JR�IMMIM�MM�IR�RM.�iA�I.M RMM MM i�M�IM IMM�MN IIM MM�Mw Mw�wM l�w.�1R�IM.N i�A MR�MM lMM�1M�MM�MRIM�M.w�1M Mw-�iw- IMwW- <br /> rerirmw111rllrrs,serrrmrmleMlwcmrrfRllumw,wlsew,rRwmwimllmeramlmIwlwmwmwrmKIIlllmwwmwawllwmlwlRr,amwAlrnslma�llell,�wrmwmwwNlll,avmw�s,wlmrelull melmwMc Rlilmrrw,w <br /> EN 23 1132 (REV 1/10/91) ft Psoe 11 <br />