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SAN JOAOUIN COUNTY PUBLIC HEALTH SERVICE(# <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNOERGROJND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> F <br /> A <br /> I FACILITY ADDRESS-w. SITE PHONE # with AREA CODE <br /> L <br /> T CITY STATE ZIP CODE # of TANKS <br /> Y at SITE <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE # WITH AREA CODE <br /> C <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPA CATION <br /> T CLOSURE, INSTALLATION, etc. <br /> TOTAL <br /> A <br /> C 1986 1987 198H 1989 1990 <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) - $100.00 <br /> 1J S �OZ� <br /> V <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> F 6 Tanks 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (multiply . y fee for <br /> C each year applicable) /) '/ S <br /> 1 <br /> L STATE SURCHARGE = $56.00 each TANK (Due every 5 years) See California H 8 S Code, Section 25287 <br /> t <br /> T # Tanks- n 556.00 1986 through 7990 1997 through 1996 <br /> Y (enter amount and year) <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. #(s) �f <br /> C <br /> L CLOSURE FEE = 553.00 per hour (3 hours minis per TANK).. .. - = TAur... .2- - - - 5 77 <br /> S - <br /> U '- —=_-DOROTHY L BNOWN= _ <br /> RALHENAISPROIMLS <br /> ---- <br /> E -- 77-, f d_SE-W <br /> L a PIAS r�J <br /> A PAY TO THE <br /> N <br /> ORDER OFS <br /> / OLLARS <br /> i <br /> R <br /> r{ _ -- <br /> rtLL <br /> P <br /> A _ <br /> M 573.001hr S <br /> I <br /> S <br /> C I CONSULTATION FEE = 553.00/hr SAMPLING INSPECTION FEE = 553.00/hr E <br /> TOTAL DUE E <br /> CFFICE USE ONLY <br /> .............._.............................................._....^.. ....._..........................._............ . .... ._.... ...._..._. .. .... ........ . .. <br /> ......,,�,....�.,..»..,...w.�.......e».v.+.... :;:z:.'a>iiN.d.S::.ew eb.»r:::....»..".Me:i::::..o.e.:Fes...:.:::. .,... <br /> vs�mn=m ===c <br /> �.cc�S COMPUTER L0. C,.De �(5'°=C013E��"/iNCU17Y��Cm�' ZNc C�! :%CASH EC�Ic� ol"� =°O�c�"R1=Cc ic <br /> Is <br /> 5 G 001f2Z?7 J 2" <br /> :2. ..r 1� ..... .. 1.. .... q._ : .. .. (... 1..... ... <br /> EH 23032 (REY 4/8/91) ft Paoe 17 <br />