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6N JOAOUIN COUNTY PUBLIC HEALTH SERVICES 16 <br /> ENVIRONMENTAL HEALTH OIVISiCN <br /> UNDERGRCUNO STORAGE TANK PROGRAM FEE UORKSH£ET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> C <br /> LFACILITY ADDRESS SITE PHONE # with AREA CODE <br /> 1 -3 :5 <br /> TC[TY STATE ZIP CODE 9 of TANKS <br /> .- <br /> Y �/ �46 - b e1'� at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P , � `w <br /> L <br /> I HAILING ADDRESS ` f� APPLICANT PHONE # WITH-AREA CODE <br /> A <br /> N CITY �, STATE ZIP CODE TY f APPLICATION <br /> T Mo �C'bs I/Z�'. �'f� cLnsl, INSTALLATION, etc. <br /> A <br /> TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 <br /> I <br /> v '' '� t7 X00" I0U s 7ov <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 9 Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multip(y # by fee for - <br /> C each year applicable) 150 150 -560 360 /$v fJC35[� .1 <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> I <br /> T 0 Tanks x $56.00 1986 through 1440 1941 through 1996 <br /> Y (enter amount and year) <br /> / C� < � & <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Plaee) TANK I.O. #(s) <br /> C <br /> MOOESTO BANKING COMPANY gd-3T�Zf 1211 s � • f <br /> EOCe MCH ENIfY A�Eff VE <br /> MODES 0. CALIFORNIA 90350 <br /> SEMCO <br /> 3523 <br /> GFNERAL ENGINEERING & ENVIRONMENTAL CONTRACTOR <br /> 431 W, HATCH RD. (209) 524-9653 <br /> MODESTO,CALIFORNIA 95351 <br /> Y DOLLARS LEI <br /> TO THE OR&IR OF DATE CHECK NO. AMOIJf4i' <br /> SEMCO <br /> S <br /> 11' <br /> - -- �s 5W0 <br /> OFFICE USE ONLY <br /> O <br /> d <br /> 1 <br /> C <br /> ........................�' S1 3 _ <br /> Ilfr ro»xoea mo»oew:roe Agee weAoe uveae pfe:ew»xvrs,�s:<so:fw;o xso:�eo:u..:u:a:e;cafa:e:..:;:;. ,. ..••..•••........•.. •'• .• ••C . <br /> P crL � <br /> .1 J M'fie(MIO N+: •.•ie0f»woene..Ao..:A»eoeser efw.www ••••••� �{ <br /> %ewe <br /> »�'33Ep5 LdtI ''COTl 15TC. E,:,: ...A)dQl)tIT RCV[)::...... CHECK" IC4A:.....:R-a4Y8Yk <br /> r <br /> a <br /> 4 i• � <br /> AM1<...................... ........................ ..............,................... ...............,.......,....., ....,............... <br /> Awe Aww Aee mm A.e mm W e JEW)eae rm Aa xtl.Oe:Lfe:ltft e'N f e^tp:JOJ:fb:S9.� K 4i ti <hl ••"'•"""',•••••••••••••...•.•...•....•...,........,......{ <br /> 2W >tA1I ASlOelit7Ail11�yK ATF AbK ltlNb7?A1A,4�L75F.Y>3t7.Y:1`Y S`5.:....Y.:.'f..r.?x::,.5 ;:iY:^.3.,v..Y�.: ., a may'':";ie:"•;.ro saf <br /> :wYekfc.w4ee=AIM ftumkef.wY"AVm IDa ae A.SN WM>lWMAU%W'W <br /> cu 7i <br /> ng,) focal 17/PA/Qm ft p;roR `1 <br /> e <br />