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' v <br /> SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY CONTACT NAME <br /> FACILITY SITE NAME FD GOTELLI <br /> A TELLI LIFT TRUCK SERVICE <br /> C - SITE PHONE Al with AREA CODE <br /> I FACILITY ADDRESS <br /> 1856 OMAY <br /> STATE ZIP CODE IT of TANKS <br /> I CITY <br /> Y TOCKTON <br /> ED <br /> CONTACT HANE <br /> A APPLICANT/BILLING NAME W GOTELLI <br /> ° TELLI LIFT TRUCK SERVICE <br /> P <br /> L APPLICANT PHONE # WITH AREA CODE <br /> 1 NAILING ADDRESS 209) 465 3609 <br /> D 856 NORTH BRIAOWAY <br /> A TATE E TYPE of APPLICATION <br /> T <br /> CITY <br /> �A CLOSURE, INSTALLATION, etc. CLOSURE <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> C <br /> 1 ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.0 $ <br /> 1 <br /> V $170/TANK (after January 1, 1991) <br /> E TANK FEE _ $50.00/TANK (prior to January 1,1991) <br /> F N Tanks = ,_ 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> AA (multiply # by fee for $ <br /> each year applicable) <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 6 S Code, Section 2528 <br /> 1 1986 through 1990 1991 through 1996 <br /> T N Tanks__ K $56.00 $ <br /> Y (enter -ii umt and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) $ <br /> C X $159.00 = 319.00 <br /> L CLOSURE SEE _ $53.00 per hour (3 hours mi nimun per TANKI <br /> 0 <br /> S <br /> R DATE REF NO. AMOUNT <br /> E FALCON ENERGY <br /> ASSOCIATES 4558 <br /> 6540 SO.AUSTIN RO. <br /> P STOCKTON,CA 95213 <br /> L <br /> A � <br /> N PAY DOLLARS <br /> DATE PAY TO THE OR ER OF CHECK NO. OR SS AMOUNT DISCOUNT CHECK AMOUNT <br /> IA <br /> BANK OF ANP O DRAWEERICA RAB 9STTOCKTTON. <br /> <br /> <br /> <br /> vrnww. ..... ..........................................................................._.. p_Fy1 <br /> ....... ....................................... <br /> q� <br /> ..... rwsrmxexww�werrr»+w /1.NS11 Nt ItI VLU el -•••••••_� OAIE Kt1. <br /> 'ITM SVCLI'$ R _ I q <br /> a <br /> .... ..... ....................... rAnerrNxarlKwwrKAwASrKNrxaAwK <br /> AirAie wAwfK uA'"wAuar�iowu�a'"air�wr �a....»� � � �5T1es+�wK� �'�'�piwxaT _ <br /> Paae 11 <br /> EN 23 032 (REV 1/10/91) it ,.� <br />