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`-'SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME <br /> F n 1 !FACILITY CONTACT NAME / <br /> A l JIAuL <br /> - t�� l' , <br /> I FACILITY ADDRESS _,�_ <br /> L lF � Sill PITON with AREA CODE <br /> I r _r� <br /> T CITY STATE ZIP CODE 0 of TANKS <br /> Y n 1 <br /> 1 cYh��. at SITE <br /> 1 A APPLICANT/BILLING NAME <br /> APPLICANT CONTACT NAME <br /> P <br /> (/ pp <br /> I ILING AADDRESS 1 ,) ' ) rf`T CIf-�i1 <br /> A /1) / APPLICANT PANE p WITH AREA-c E <br /> N CITY 1,110 VJ \Up'� <br /> \I'� I' STA E ZIP CODE c� TYPE f APPLICATION <br /> V ( - I I- ( .� OSU36, INSTALLATION, /) Oc. , . <br /> ANNUAL FACILITY FEE (prior to January 1, 1991) _ $100.00 <br /> A l <br /> C TOTAL <br /> T 1986 1987 1988 1989 1990 <br /> I <br /> v S <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) $170/TANK (after January 1, 1991) <br /> F :ea:ch <br /> nks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> At(ply K by fee for <br /> C year applicable) <br /> I S <br /> ( STATE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California H $ S Code, Section 25287 <br /> T M Tanks x $56.00 1986 through 1990 <br /> T (enter embtn[ and year) 1991 through 1996 <br /> t <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. p(s) ) <br /> C <br /> L <br /> CLOSURE FEE _ $53.00 per hour (3 hours minimum per TANK) p TANK(s)___�__ K <br /> CRISP TANK TESTING i CONST. CO., INC. <br /> PETTY CASH ACCOUNT /. 8 <br /> 931-1828 T <br /> P.O. BOX 304x7 )0 = f <br /> STOCKTON,CA 95213 <br /> 19 <br /> Pay b the <br /> Order of Q <br /> f <br /> Dollars <br /> • Il l lnterslat Bank <br /> I'1/St of California 61 <br /> �� <br /> Interstate 4932 Pacific Avenue <br /> Ba k P.O.So.7485 ))) <br /> Slocklon, CA 95207.0485 '/ •DD = f <br /> U <br /> w f <br /> FEE - S53.00/hr FEE _ $53.00/hr FEE _ $53.00/hr <br /> f <br /> TOTAL DUE f <br /> OFFICE USE ONLY It <br /> :....w»47:...r.:............................................... __ <br /> .. ............. <br /> ( ' $ <br /> .' . _..... , ».». ::..� �. ....�... .��.......... E�T�l if"" 'f J"" "w 1'A ;). '61StA'n",� - a <br /> aaw�aewawrrrawwwiwwemrzarttuvxsrawrea»•••»,•NiOpi•=••°°°'•w :»,;»,:;,».».:;;:,,;,.......... l )� <br /> xxwtmttattxxttttxrttxasxxrttxxxtt;rx rmtts ttencM.e 11 xttsxr p�veumr xcavmxawttruttxam'='.tu'�r as,q j yr My^ <br /> EN 23 032 (REV 12/26/90) It Paae 11 <br />