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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH 01VISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME/ /�/� �L FACILITY CONTACT NAME: j�Ir ° <br /> F r /�/L / f� ���I � '-f-/}'t"` � (!(0 5"v ��,.. i/Cct !'fie <br /> A c � QLD <br /> I FACILITY ADDRESS SITE PHONE 9 with AREA CODE LA)[N^' �Z{ <br /> STATE ZIP CODE A' of TANKS <br /> T CITY.:¢� �p [ at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> L <br /> CKAILING ADDRESS l C! / f� /f APPLICANT PHONE !f WITH -AREA CODE <br /> 1l/Q <br /> N CITY / {STATE ZIP CODE FY f APPLICATION <br /> T ''10 ���� LOS INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) ' 5100.00 <br /> 100- o— deb` 100._ 70 6) <br /> v - <br /> E TANK FEE 150.00/TAIIK (prior to January 1,1991) %170jTANK (after January 1, 1991) <br /> F R Tanks n 1984 1987 1 1988 1 1989 1990 1991 1992 1993 1994 1995 1946 <br /> A (multiply fee for <br /> C each year applicable) W6 /_jp 3607 3WI <br /> L STATE SURCHARGE = 556,00 eacK TAIIK (Due every 5 years) See California H IZ S Code, Section 25287 <br /> 1 <br /> r # Tanks x %56.00 1986 6rough 1990 1991 through 1996 <br /> Y (enter amount and year) A <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(s) <br /> C -7 <br /> L CLOSURE FEE . $53.00 rwr h.,.. .� L '-- - Ma}b�irb �Atv►cl�Ia coflpANV 90-37 11211 I <br /> �- itee� McfI�HNY AVIL"ur <br /> ' I.iaa�+*a.eNt.IeaMNirt■eido <br /> semco S <br /> 3523 <br /> 6EN F_A AL LrN�I1J 1tt 1l lfl Ly rNVt*CF1M 1•rIYAL ct3 Ny'h llC#Oa <br /> 431 W. HA-tCH no, (209) 62A-3853 r <br /> MODES16,CAOMFINIA 95351 <br /> j .� DOLLARS <br /> PA i„ .5L`Wla rzk.af4�* klRik' �#il4fsit Aldkbh9l#�' 'k <br /> SEMcv <br /> i <br /> I <br /> y TOTAL DUE <br /> OFFICE USE ONLY _ 300 - r5jgo S, JSP Ot `C� • � Gv� <br /> ........_..................................................... <br /> ,.....,. I rN <br /> � t: xtrxotatn c t �+xi�xt+a (( <br /> II <br /> R$,isi c'ct� „ ,-'A�I.9otiilY' c '>x'�' H Hca }i'YMW9"T -r`�i'g`h�c"�1'�E�'`.`""� <br /> I.l.a-�. ...tth�ufa .....................................y <br /> II.I Y.�MMy MN MMIC MN MMM MN' I MMM MMN MN MIf x4�;Ieat.}xt1,^Y.1 xSM:NARYM 3 t'+e1 fM�M 'Mb Y,O K4 P x}`C a O Y6 Mr►Ytttl:i: M[�N MN MIIM%N XM MMIC AI.1 MMN III►MMN LIN IIIIR twI MN MMII yw iIN <br /> in w AUVO lMt mw IMI NCIH mm ilea mm AAY➢rgt 03 a," r*vA.xM%"M f.;i..�, s?�`W`.YS s5�p6�i MtLY�I�Yl)0.t fYY1M A61i"m fM pCt:Wilr ltitlMt � <br /> ru )-t n77 eary 1712Ai0fi1 ft Pnaq I1 <br />