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S' 'OAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGIM UND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F <br /> FACILITY SITE NUV£ FACILITY CONTACT NAME <br /> C <br /> 1 F Il T ADORE S I SITE PHONE 5 with AREA CODE <br /> L <br /> I M'qlyLad / _ <br /> I <br /> I CITY / STA ZIP CODE 0 of TANKS <br /> T L a st SITE D n <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE / WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE SyPE_ ff APPLICATION <br /> I CLOSURE` INSTALLATION, ett:. CIU 1 <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> I ANNUAL FACILITY FEE (Prior to January I, 1991) • $100.00 <br /> I S <br /> V <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) 5170/7ANK (after January 1, 1991) <br /> F / Tanks 7986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (sul tiply i k fee for <br /> C each year applicable) S <br /> I <br /> L STATE SURCHARGE • $56.00 each TANK (Due every 5 years) See California H S S Code, Sectl on 25287 <br /> 1 <br /> T 1 / Tsr*s x $56.00 1966 through 1990 1991 through 1996 <br /> T (enter saount and year) <br /> S <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. /(s) <br /> C <br /> L CLOSURE FEE • $53.00 per hour (3 hours minimum per TANK) A TANK(a)�, K $159.00 • 5 Q <br /> 0 <br /> S <br /> W ��gp , to I li11 '.yr lig V <br /> ujRln w- TM+K TE�TIP10 LF�1�lI7 � f.rl '$ i rJJ if ;< — - -0164#00"'3:15` <br /> R 'I I PETTY CAW ri to flll'I 1{I- Q <br /> f ,l ffr ! FJFR i 1/Ff <br /> E �I1, g� e2eAG51�NMiii i' s l r#F� °Alla ` <br /> 1 ,l r nr1i tnon r nl �, c s <br /> ,Irflfrn n,. I}I}rYFFF}F)F)FIFJr! f!E, i I{r 9jrlT�,�,t <br /> 1{ rrilr$nri. STOCK c � N °} 79 /; <br /> P .frK fnfitfJ. <br /> L '!I)f!I ;r. ..SIF} r J R !� r•}^ <br /> PAY TO'1'1 t- !i 7!7 r t rl r f I r)srrr <br /> A t7R� r d +fr , ro _ ti :rnlrl p' F,r rn fr. $� <br /> R wnKf rlatln. I�f1 NNJAJrl"N' I -Ii/NIR<IIf! i it/rr.r:, 5 <br /> r ( £ir }(�F(i)}'iL'II, MARS <br /> R ;1I1 If1 �NfUel,Irr� l7 I f ! IFjF/F rI F"l`f `ilk Ii��1/I 1rl�tif'fl�l�lflfiF7��r,�!_1 £Fjil)lr//, <br /> E r Fl rPftftwft <br /> IJ// ))f FlFlrft Kfl FIFCrilr - 5 <br /> llD awl AMle� !f. }F} ! IF !# lr 77�i�i lrlpll rFn FF l <br /> r_ { .1F/I <br /> frtOOW6 SAk 1 I IFI Ff{)if�r �l-i{')1}#i° !'!!`YtFVTI !J�-ft�F f}F7F1 r;. <br /> . titin ,+.HI III! F}F r)F}F}r fr r JI' ti1Ff f yrgiFlCMNfie <br /> R P �A7eYti f' F r 1 Ci , f r . r "e 't r I r Ff6! r " 5 <br /> IFJ <br /> y� <br /> F.• f F f r -n I I I I f f!� 7 rI lFl ( iF N!F Jfll E}r fN./I}FnFA�! to <br /> 4 2 4Q I• ,�a1:�9 ; #; .1 1i71#II II. - F F' _fir„. <br /> N r011 , <br /> 1 na•rtvaar w.c - . <br /> 5 <br /> C FEE • 553.00/hr FEE • S53.00/hr FEE 5 53.00/hr <br /> TOTAL DUE OU <br /> OFFICE USE ONLY <br /> a'19Elfii"7” 7 7771 <br /> 8iF" —"sTLRr 'AI�A}Y•}lL'Cifm1."1111'117 A�E10Eff"VP""•r '1 F'1t6Z'tT1Efl" <br /> 5 .60 : <br /> wrrwrwrrrrrrrrwrwwrwrwrrwrrrwrwrwwrwrwr•.wrwwwrwwrr,trwwwww <br /> EN 23 032 (REV 1/10/911 it Paae 11 <br />