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' SAN JOAOUIM COUNTY PUPLIC HEALTH SERVICES - ENVIRONMENTAL HEALTH OIVSION <br /> - UNDEM D STORAGE TANK PROGRAM - FEE UORKSIIEET <br /> T SITE NAME FACILITY CONTACT 6E <br /> Barbara CamphelI Same <br /> .IIItY ADDRESS SITE PHONE N with AREA CODE <br /> 213 L. Oak U. N/A <br /> I fly STATE 21P CODE N of TANKS <br /> A Lod 1 n CA 95A0 at SITE I <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> I I Barbara Campbell Same <br /> C RAIIING ADDRESS APPLICANT PHONE N WIT" AREA CODE <br /> A 1•151 W. Satil.a Ana (209)222-8210 <br /> 1 f.I IY STATE 21P CODE TYPE of APPLICATION 11emovaI <br /> I're3i io CA 93'105 (Closure, Installation, etc.) <br /> TOTAL <br /> 1986 1987 1988 1989 1990 <br /> AHIIOAI. FACILITY FEE (Prior to January 1, 1991) = 1100.00 <br /> A f <br /> I fACjliiy PENALTY FEES ASSESSED (If Applicable) xxxx xxxx f <br /> -__ <br /> V TANK FEE _ 1150.00/1ANK (Prior to January 1,1991) 1170/TANK Ufter Jenlery 1, 1991) <br /> F ____._ <br /> $ tanks _I_ 1xxxx <br /> 1987 1988 1989 1990 1991 1992 1993k1994 1995 1996 <br /> I (a.,10ply 1 by fee for - - <br /> A each year aMticebte) X X X X X X X $112.00 <br /> r. <br /> I TANK PENALTY FEES ASSESSED xxxx $ <br /> I 51AIE SURCHARGE _ $56.00 each TANK (Due every 5 years) See California N 6 S Code, Section 25287 <br /> 1 M Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> (Enter amount and year) <br /> f <br /> C PEY (ace) TANK I.D. M(a) <br /> n CLE (�// 1� r/ 0 TANK(s) 1 x $234.00 $234.00 <br /> O IEP TANK I.D. $(a) <br /> g�,/�/ ,�� FACILITY) _ $234.00 minima f <br /> P ITIS 6cpe-p �Q/ I--WCtlons) TANK 1.0. N(a) <br /> I <br /> A <br /> D Pt n Y) - $624.00 mini Asa f <br /> R REP s) TANK I.D. f(a) <br /> F <br /> P FAN rTANK) N TANK(s) x $234.00 If <br /> A - <br /> I TAN FACILITY) _ $234.00 minima f <br /> R -- <br /> pip .y TY) • $234.00 minima f <br /> 11 IRnbnre= Fee sev.w L1%)..v"j(Miztu acre ASE EVAI.UAfIOIF - (78.00/hr f <br /> — <br /> 5 _ <br /> C CONSULTATION FEE _ $78.00/hr SAMPLING INSPECTION FEE • 178.00/hr ! <br /> TOTAL DUE 3116,00 <br /> TOR OFFICE USE ONLY <br /> clFFKS m <br /> °1111'r0�{�fTf� L7n'.en�'t3�i '�f sic ) " 41Pf[1�i"f1Z'21U�6 ftt�'�90/�d4fla" "1Pk'tFk'1CL'8"9Y"a'a" I T T EIVtU i <br /> a ........... .1........ <br /> .......... <br /> .... <br /> .L.-.........�........................�...............................�.............................. .................................. <br /> �.......................................i <br /> •W.Mw.w�.wM w•.�... <br /> •r=Yr^v1.-ae+Ja WRMW AM AM AXYI AW MiIa A=I AaAYAtl AGWAY AW AWaA4.lWe AYIAM(Al AN nNW AW AYMI Ma AMMr AW ANM MM AKAMW AWAIUr MW AIYMAW AWAAWIAW AMW MM IImY AMMMW.AV AM Aa1W AW as <br /> (n 71 OS2 (REVISED .1-1-911 Pane 11 <br />