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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES U o <br /> ENVIRONMENTAL HEALTH DIVISION D'Lt yaYs I <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET 7/ ne Teo-�tY` <br /> F FACILITY SITE NAME 4FACILITYCONTACT NAME � a.1 /jbAC1 FACILITY ADDRESS E PHONE # with AREA CODE (N' <br /> L A 3 5(v ' <br /> 1 f_ �, <br /> T CITY. 1�� STATE ZIP CODE # of TANKS <br /> Y i p�\ t va b�� at SITE <br /> I ZA <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> CKAILING ADDRESS l 1� �� � �C APPLICANT PHONE # lllTH AREA CODE <br /> A f T/ <br /> N CITY ]/�j Q ,L, STATE JZIP CODE TY f APPLICATION <br /> T !/iD C�CP� [/� CLOSU INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I r � ley 0` ?66" 100— S 70Ca r <br /> V <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F # Tanks R 1986 1987 1988 1989 1990 1991 1992 1993 1994 1495 1496 <br /> A (multiply # by fee for <br /> C each year applicable) f5�} jsa 3CU 360 �1 0 $Id 50 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H B S Code, Section 25287 <br /> I <br /> T # Tanks x $56.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) J <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) <br /> t <br /> L CLOSURE FEE __ S53-00 rwr.hn.�.rx L-----...• .-_ _. .. <br /> MODES-rO BANKING COMPANY 90-373211211 �77 <br /> sOCl "Ci4mm 1y AVENUE <br /> MOOe%TO,CALIFORNIA 96990 <br /> SEMCO 3523 <br /> GENERAL ENGINEe:RIN[' 6 gNVIRONMENTAL CONTRkCYOR <br /> 431 W. HATCH A0. (709) 524-9553 <br /> MOOESTO,CALIFORNIA 95351 <br /> yr„ DOLLARS <br /> PA <br /> .� trAtM L�M6CK No. AM604i' <br /> T4 THE 014 R Dt+ <br /> SCO <br /> TOTAL DUE S'� <br /> OFFICE USE ONLY ~� <br /> ........................................................................... vv <br /> � 3 <br /> S t <br /> V fS�r�G P L�L <br /> �...x.o.. .�...�.�,.,.��..�.,..�.,. ........................... <br /> .............:............ <br /> 4 <br /> .cwo��v:uaa:Ie.:c-w.s xc «woaK e .+.v att��t.:.n.x.a taw.ao.pa»w.�na ro«rAw wwi�j.w w«we.elw�iw'i iei.:w y11!Cit <br /> 'col 1Sl CME..,' "-Aloull-' R"[14} RCW'Y�Y�,. > <br /> :...R.N.L.da--fI.21 n.��1 - 3 L s�(sT �� `rz' 3533 *f-� <br /> rssrcoo:ieie:to%; r:'ru::'eo x%%i:s:ti:i%::9 .,y;. .....• .....,!. .J �.[..... <br /> Ipgr Atlif AOAOSA AigI A711r MAiXfAIF*ArAR�AtApY RL6 AbXY#lj>>LyY:J'ij : 'h�i x'ewi'ai.Iie.iinii ai.i i.w iilii.iiri i.w <br /> `M".2".{ AW Alf(AVW AW AWM AW AW Ater AW Ak%WV M IXAr <br /> ru 73 nil rocv 1719(,/om fr PAOR 11 <br />