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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES - ENVIRONMENTAL REA)" DIVSION <br /> uw)r 'AAD STORAGE TANK PROGRAM - FEE WORKSHEET <br /> S FACJ.L,ITT SITE NAME FACILITY CONTACT NAME <br /> I Lyp) <br /> T <br /> E FACILITY ADDRESS 417E HONE N with EA CODE <br /> 3 d <br /> CITY STATE ZIP CODE / of TANKS <br /> A at SITE <br /> P <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L <br /> I <br /> C NAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> A <br /> M <br /> T CITY STATE ZIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) <br /> TOTAL <br /> 1966 1987 1988 1969 1990 <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) _ $100.00 <br /> A xxxx xxxx S <br /> C <br /> T FACILITY PENALTY FEES ASSESSED (If Appliceble) xxxx xxxx S <br /> I <br /> V TANK FEE 550.00/TANK (Prior to January 1,1991) $170/TANK (After January 1, 1991) <br /> E <br /> M Tanks 1986 1987 1988j 19897m- <br /> 1993 1994 1995 1996 <br /> F (mdt(p(y 71W-fee for <br /> A each year applicable) xxxx xxxx f <br /> C <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx S <br /> L <br /> I STATE SURCHARGE _ 156.00 each TANK (Due every 5 years) See Call}ornla N i 5 Code, Section 25287 <br /> T <br /> T N Tanks A $56.00 1988 through 1990 1991 through 1996 <br /> (Enter aaqunt erd year) I T / <br /> J �'�-f VC; <br /> C PERMANENT CLOSURE (R anov.( or Authorized Closure-in-Glace) TANK I.D. N(a) <br /> L <br /> FISCH ENVIRONMENTAL 2-94 7156 <br /> CONSTRUCTION SERVICES o s <br /> PH. 209-367-4583 2/1211.1040 W. KETTI-WAN LN. 26754LOOT, CA 95240 )yd.l—ORD,RO�rrFJAH ,�L✓�C � $ _....J <br /> S,/rw `'\L.d__nvv.ANreLx 4.A&A '�l.JG1tJC. � S °!/p A R 5 <br /> 0 of Lodi 00 = $ <br /> I f <br /> N TRANSFER FEE = 126.00 UNAUTHOR12ED RELEASE EVALUATION = 376.00/hr S <br /> t <br /> S <br /> C CONSULTATION FEE = 178.00/hr SAMPLING INSPECTION FEE = 378.00/hr f <br /> /e [- TOTAL <br /> FOR OFFICE USE ONLY �Lu` """�- S'�•(/t GOfK'tggp�� <br /> .!mnmmmm!rm!mm!mnnmmen!mn!!mimmn�mmnnq!nemm!m!!mmrmmmmnmmmmrmM, mmnmmr!nmmmnmmamrmmm� ... .mmnnRamnmm!mmmmtemmmamau nmmr!v!!mmmm!mmnrmmn!!mnmma <br /> m ...m:nm+nmN+Inn�nsa rr .r.rnn !.u!!!. im.u,.d:. �n:onrr!nmm:�:nrrnmm!tu,ur rn,.!..!,.!nn!nc!m�+mei!amnwrm�,:n!.,r:nn�n� nr::l! !vnnrma::nirn!n 111!r.! a !_!nn!!!.nLF:�nri !!!,=.9 .r!! JCFTma::i!!m <br /> SWEEPS a COMPUTER Al LOC CODE DIST COTE AMOUNT RECEIVED CHECK M/CASH RECEIVED BY DATE RECEIVED <br /> .. __.......!:.... _ ..: <br /> m!cu-nmm <br /> N , n.a.,!m.!:m!n!onA1.!:T ^n, _ Ilm!!.!,.m . cm!r! ::m,ym!!!;!�o!! _m!!m-!:m..m!em!mm! <br /> EN 23 032 (REVISED 6-21-93) Page 11 <br /> � v <br />