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psly �LTAL2MN JOAIXIIM COIRITT INISLICLTO SERVICES - ENvHEALTH DIVStaN PAYMENT <br /> UNDEROROIMD SiORRUIN RAM FEE 1bRKSHEET <br /> 5 FACILITY SITE NAME FACT Iii CONSy�eT NAME <br /> 5 tv ti e t�cz/ i d/O ►V�V 17 19", <br /> F. FACILITY ADDRESS p E sm it / NIM AREA OmE JOAQL: <br /> 6 <br /> FO I"Q� Noce 7 20 -6 C/-/� PUBLIC HEA; ', <br /> CITY STATE LSO <br /> CODE / of TANKS <br /> A �'lock �Ql� � 7SO0 6 •T E•1E <br /> P <br /> P APPLIrANT/BILLING KAMEAPPUCANi ACf NAME <br /> 1cc- /'— <br /> C MAILING ADD SS APP (CANT PHONE / WITH AREA CODE <br /> M 22 � S Torg �d �iy -q,59-1500 <br /> G / PPLITIO <br /> Irotallat <br /> ln,O✓C$i C1iT CeteJ <br /> TOTAL <br /> 1986 1987 19M 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) • $100.00 <br /> f <br /> CIf <br /> T FACILITY PENALTY FEES ASSESSED (If Appllceble) xxxx XX701 S <br /> V STANK FEE SSO.00/TANK (Prior to January 1,1991) SlTO/TANK (After January 1, 1991) <br /> F - <br /> Ie tanks 1986 1987 1086 1909 1990 1991 1992 1993 1994 1995 1996 <br /> F ' (mu(tlply I byby fee for <br /> A each year applicable) f <br /> I RANK PENALTY FEES ASSESSED XXXX XXXX 1 <br /> I STATE SURCHARGE • 156.00 each TANK (Due every S years) See Cal ifomle H S S Code, Section 25287 <br /> i <br /> Y R TAnks x (56.00 1986 through 1990 1991 through 1996 <br /> (Enter ;;&-mt end year) <br /> E= <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-In-Place) TANK I.D. /(a) <br /> L OU <br /> D CLOSURE FEE • 678.00/hour (3 hour$ NIninin/TANK) 0 TANK(*)_ X 9734.00 <br /> S <br /> U TEWMRY CLOSME (Plan Review 5 Inspectims) TANK I.D. B(a) <br /> R <br /> E TEMPORARY CLOSURE FEE • 578.00/hour (3 hour$ minim.ANFACILI7T) • 5234.00 NIn1NAlll 1 <br /> L SIMUNACI EARTH MOVING T 2304 <br /> A BRENDEN SIMUNACI, OWNER ` <br /> CONTA. LIC. 819757 LIC. C3439446 1 <br /> P. O. BOX 982 PH. 209-532-8719 j6_ „/"� <br /> COLUMBIA,CA 95310 !! 7 <br /> R I — <br /> E PIN IU THE�^�)fI T /, //,yam �` P `/, �/ O <br /> POFr..Lw!/- V Fil� � �7/u 6 �(/!/� r/ O S <br /> .I EL CAPITAN NATIONAL BANK <br /> 011 <br /> Iya wc..�mcaro.aw•.r +vr m �� <br /> w«v..cuonnu+sem 5 <br /> t 1 <br /> FM OFFICE USE ONLY _ _ __-- <br /> »,,e.�:Ti�w <br /> "'1l1Sfi•c'd1E" At�fA'r'4IE4!!'IVE6 Tte" " -FAR <br /> c�' R"ANAc <br /> "" <br /> • S <br /> 1 —J <br /> �-;^::.0—w --•�•—�—_ ---�—•••-wwi •—"'�:---w—'-'-w+�.w�w.w rw`a��•^w.rr` "r'.Gwwi w,ww.w�G ww ter.• <br /> wwa.r•.•iF a•�'isii�wAi�wiriwerw ++�wA:�wwa`w 1AFw•wwwawwwAal�wn wYwwarw wtwrarw wrwwwww <br /> P: 23 012 (REVISED 3.1-931 PAoe 11 <br />