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SAN JOAOIIINPUBLIC HEALTH` SERVICES - ENVIR ONNENTALTH DIVSION <br /> RGRCIJM) STCRACE TANK PROGRAM - FEE WORKSN <br /> FA <br /> FACILITY SITE NAME <br /> � �i L/ FACILITY.CONTACT NAME <br /> Y ADDRESS ` iSITE PHONE f NiAREA CCaE <br /> L/S ) C/JJ STATE ZIP CCOE _ x o TANKS <br /> !C�1,../ - i at SITE <br /> P APPLICANT/BILLING NAME <br /> L APPLICANT CONTACT NAME <br /> I <br /> C NAILING ADDRESS <br /> A APPLICANT PHONE 0 WITH AREA CCOE <br /> N <br /> T CITY <br /> STATE ZIP CODE TYPE of APPLICATION — /t:, <br /> (Closure, Installation, etc.) <br /> • � �� TOTAL <br /> A l., <br /> ANNUAL FACILITY FEE (Prior to January 1, 1991) = 5700.00 19 1987 1988 1989 1990 19 51 O <br /> G XXXX XXXX F 5 <br /> T FACILITY PENALTY FEES ASSESSED (If App(icabte) I l� <br /> I XX)x X)= O S <br /> V TANK FEE = S50.00/TANK (prior-CoJ ry 1,)qq1) <br /> E 5170/TANK (After January 1, 1991) �- <br /> Y Tanks = 1986 98.. 1988 1989 11990 1991 11992 1993 <br /> F (multiply 9 by fee for 1994 1995 1996 <br /> A each year applicable) XXXX XXYX <br /> o v Z/v <br /> I TANK PENALTY 311) <br /> FEES ASSESSED XXXX %XXX <br /> L Ll i) 5 <br /> [ STATE SURCHARGE = S56.00 each TANK (Due every 5 years) See California H b S Code, Section 25297 <br /> T <br /> Y 9 Tanks.. —X 556.00 1988 through 1990 <br /> (Enter amount and year) 1991 through 1996 <br /> / / 5 iA <br /> C PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) <br /> L TANK I.0. X(s) <br /> OI CLOSURE FEE 578 00/hour (3 hours minimum/TANK) <br /> i S X TANK(s) <o�. <br /> •:� >;� <br /> 3292 <br /> ZAHID CORPORATION <br /> BELL GAS & MINI MART <br /> 4400 RALEY BLVD (916) 927-2118 <br /> SACRAMENTO, CA 95838 11=35 <br /> p L C7 <br /> )all1210 <br /> li�,Oromt-, � -t <br /> L- <br /> [}�Bank of America <br /> Rio Unde 9ianch 0985 (9161 373{9�ll <br /> Ilio Linda.7567 <br /> 11100329211■ i: i210003581: 096SSell i � 34411' <br /> a~LINa INSPECTION FEE = 578.00/hr <br /> S <br /> TOTAL DUE S <br /> FOR OFFICE USE ONLY <br /> SWEEPS x CCMPUTER 9 LOC CODE DIST CODE AHwNL RECEIVED CHECK ;t/CASH <br /> RECEIVED BY I DATE RECEIVED <br /> EH 23 032 (REVISED 10-28-93) Page 11 <br />