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SAN JOAQUIN COUNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> GROUND STORAGE TANK PROGRAM FEE WORKSHEE4 <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A Dependable Precision Mfg. , Inc. Cliff Mc Bride <br /> C <br /> I FACILITY ADDRESS SITE PHONE 0 with AREA CODE <br /> L I I I I S. Stockton St. (209)369-1055 <br /> r <br /> T CITY STATE IIP CODE 9 of TANKS <br /> Y Lr�cl r , ca. 95240 at SITE 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P Dependable Precision Mfg. , Inc. Cliff MC Bride <br /> L <br /> I HAILING ADDRESS APPLICANT PHONE 0 WITH AREA CODE <br /> C 1111 S. Stockton St. (209) 369-1055 <br /> A <br /> N CITY STATE YIP CODE TYPE of APPLICATION <br /> T Lodi., (;a . 952/10 CLOSURE, INSTALLATION, etc. Removal <br /> A W TOTAL <br /> C 1986 1987 1988 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = SIO0.00 <br /> 1 E <br /> V — <br /> E TANK FEE _ 150.00/TANK (prior to January 1,1999) 1170/TANK (after January 1, 1991) <br /> F 0 TAnks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (mil tipty N by fee for <br /> C each year app(icable) _ <br /> 1 <br /> L STATE SURCHARGE = 556.00 each TANK (Due every 5 years) See California H R S Code, Section 25287 <br /> 1 _ <br /> T 5 Tanks x 156.00 1986 through 1990 1991 through 1996 <br /> Y (enter amount and year) <br /> S <br /> PERMANENT CLOSURE (Removat or Authorizr-d Closure-in-Place) TANK I.D. NO) <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minimum per TANK) N TANK(s)_]_ X 3159.90 = S 159.00 <br /> O <br /> TNl9 CHECK Ig DELIVERED FOR EA4MENT - - <br /> OH THL FpL"O 0 ACCOUNT.. <br /> DATE ~� AMOUNT_ AICM-MART 2223 <br /> — -- -- - JIM THORPE, DISTFF11BLIT0pRYl1,OF QUALItY PRODUCTS 11 <br /> P.O. BOX 357 368-6175 462-4581 <br /> 351 N. BECKMAN ROAD <br /> -1LODI, CA 95241-0357 156-844/1211� 9 <br /> PAY <br /> TO THE ORbL "14—. <br /> ell <br /> e -- <br /> TOTAL OF INVOICiES auk —DOLLARS <br /> LESS_ %DISCOUNT L�tNrKrF <br /> LL'S9- lrCF MEA ST <br /> TOTAL DEDUCTIY]NL9 WE""C--" N-S <br /> ■■A■ BANK 80F84ft <br /> AMOUNT Or CHECK I <br /> 00222311' '1: i2LMA411: 00L24915111 <br /> TOTAL DUE 1 159.00 <br /> OFFICE USE ONLY <br /> Lwr ww wma bw bares rtt nLea na Lot Laddw LeLe Lean ba waae ww teeaee bee ewe rwdee reap wee»rerr laew ver r�eart�re+s�ats wppw�Leeeer reel weed♦wr►oraw ww res ewrt tLw Laeea bee wtwt res foal taLLa Lwt Lw11t tea chew Leri deeew nL'�::rieei iai idii <br /> "" "C`d °°re° ' I S L �fN I R I vt1 `�, '� QIP '" P`e°`dEf`� ` <br /> " lev1: ...... ..2. :> .. ................. �'.j 1 f .............. <br /> LM res weew r«ewes I.a.!wee ra Lw ee row naw nor Har ne.neo.b«ww waw.rLw».Lee La►wLwt net Lw raw►Lwr HeLa nw news test rwt wa,wt wra LLw Lwa tat Lalw Lew LMt r.L»Ili~niLi� »wr4 iLrLi I:aw Lata.LLOIM tLw LL3a <br /> »rL rn SdM RddAf NM NedN N1Y A?e!NNN PA7,la►RY NSL Nsax Ntt Nssn!def fiaaD sNax Nsr NNsr NAL NNX NLr Nx NNx Nx Nmx flw NNA{NN NNrr Nw NAr Nx Ntrdr;ner�ALAaIr AMf!PAL NNx zw RYrtlY l�'i Mbw Asn N►Nr I�Lr Nr MLaMI NN Aeli <br /> EH 23 032 (REV 1/10/911 ft Pace 11 <br />