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S711P JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION Ci \ <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F CILltY SITE NAME FACILITY CONTACT NAME <br /> PAYIM -his cd/F_ fL�//Ycs <br /> 1 FACILITY ADDRESS OCT` PIION�^�h AREA CODE <br /> 2�1 # al/ TANKS <br /> 1 CITY / <br /> yl P "R(!r'i�J? at SITE / <br /> y c)/��.`'t%/ y ENVI EALTjI vi - <br /> A APPLICANt/BILLING NAME LA h"F VON TACT NAME <br /> P �✓EiYJT �O�vr'T ^JE` lEiYTLlcs' <br /> I HAILING ADDRESS APPLICANT PHONE IF WITH REA [ODE <br /> N CITY L�a STATE 21 �COE PPLICATION <br /> I LOSURE INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 19871988 1989 1990 <br /> 1 ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> I $ <br /> V <br /> E TANK FEE $50.00/TANK (prior to January 1,1991) !170/TANK (a/ter January 1, 1991) <br /> F IF Wanks = 1986 1987 1980 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply A by 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 6 S Code, Section 25287 <br /> 1 <br /> 1 IF ranks x $56.00 1986 through 1990 1991 through 1996 <br /> T (enter amount and year) <br /> f <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) # IANKf a) K $159.00 f �� <br /> 0 <br /> EXPLANATION AhJO <br /> $ <br /> -K 1403 r.A,.•t 2 817 - <br /> 1 85241 <br /> i9-9305 <br /> ! ARS "C14ECK $ <br /> iE 0"E\R Or A/P Dl61T RETENTION DISCOUM NETENrION (CI^IECN AMOUNT - <br /> $ <br /> ICK I IA( Ilaadqumlms - S <br /> -. STOCKTON,CA 85202 ���===ddd <br /> ' s <br /> OFFICE USE ONLY <br /> .�...�.....'.r,.S.w...... <br /> ww........aw.w...ww....wwwrww. ,wiw(we..w..r..iw.r.»..ir.„...ww....ww........ww........»»...ww........ww....w.....ewwx,w <br /> rwrw»eiwz.w.,wxiww._wnwweeii»ii,iisi.wi.e.i.ei,.iw..iiwe.w.w.w..ww....ar..,.i.Aw.'(•w.•.iiwiwo•»•iia.w•,.iiiw"ii"i <br /> w�ie"exlii <br /> ii•i.viwweieiifuifii"i-rir:i:li07C <br /> TL <br /> L ii,Tnwi( <br /> ,wwiwiwi"wiwwi'iiirwriiiwwi•••••.iiyii�w <br /> sees TU »m .......w. .......... y11 L""" <br /> •• •r"7i�••.••.www <br /> t+>.r�amuzenetsARterxasmrA¢oexasaaxsttaaaan--^¢vxxmAxpfzrx:xe�exxdmammAaxrARznRwaxaRmrraxai�AanATtmnemfaTanttasAawasttwwl�fseaw'�arxa <br /> FII ?I. 1132 IREV 4/8/911 /t Pace 11 <br />