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SAN JOAWIN C()tJNTY PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> UNDERGROUND STORAGE TANK PROGRAM FEE WORKSHEET <br /> FACILITY SITE NAME FACILITY CONTACT NAME // ` <br /> F L oh h� <br /> " VI I� _I.52 � In�ct I r� <br /> C _ SITE PHONE M with AREA CODE <br /> I FACILITY ADDRFSS <br /> L 0 1 <br /> 71STATE ZIP CODE 0of TANKS <br /> I CITY ^� C1.4-10 at SITE 7- ✓ e- <br /> T i� APPLICANT CONTACT NAME <br /> A APPLICANT/BILLING NAME <br /> � <br /> V► I���E ��,;,-I Nle�( ►)Ac., --- <br /> APPLICANT PHONE N WITH AREA CODE <br /> I MAILING ADDRESS <br /> A `,eYCre(fIC� !:]STATE ZIP CODE TYPE of APPLICATION <br /> F1 CITY ) feerdVC" CLOSURE, INSTALLATION, etc. <br /> ► � �n c'IC.�C�1 � -- 6 <br /> TOTAL <br /> A 1986 1987 1988 1989 1990 <br /> C <br /> T ANNUAL FACILITY FEE (Prior to January 1, 1991) = $100.00 ! <br /> I _ <br /> V $170/TANK (after January 1, 1991) <br /> E TANK FEE = 550.00/TANK (prior to January 1,1991) <br /> F p Tanks = 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 <br /> A (miltiply N by fee for , $ <br /> C onch year applicable) ' <br /> I <br /> L STATE SURCHARGE = $56.00 each TA14K (Due every 5 years) See California H & S Code, Section 25287 <br /> I — 1991 through 1996 <br /> I N Tanks x $56.00 1986 through 1990 <br /> T (enter amount and year) $ <br /> PERMANENT CLOSURE (Removal or Authorized Closure-in-Place) TANK I.D. N(s) <br /> C �.2 K $ <br /> L CLOSURE FEE = $53.00 per hour (3 hours minirmim per TANK) M TANK(s)_�_ <br /> n -- <br /> DATE INVOICE AMOUN A&G 1 � <br /> WESTERN METER SERVICE, INC. y <br /> 2735 TEEPEE DR. SUITE E ,n FAQ E <br /> ST0209)948.8124205 <br /> of y'SIQN <br /> DOLLARS <br /> E TO THE ORDER OF OROBS AMOUNT DISCOUNT CHECK AMOUNT <br /> OTHER ACCTS.PAYABLE <br /> 7-91 1 <br /> WESTERN METER SER l@E, INC. % <br /> UNION SAFE DEPOSIT BANK <br /> STOCKTON,CALIFORNIA r $ <br /> o0 L X6 3 lum I: L 2 1 10 L013 21: 50 1 2 51, 5811'06 $ <br /> $ 1-1 ' r I <br /> OFF I CF USF. OIII.Y <br /> :..........................:...................................................................................................................................... _ <br /> d O 1'.�:•NN00 0NO 00NM.....M NV)lO Ni0 f00ta00M0 NOOo010�0%et000cO0 N0,NNM NN%•000 k00'AOEEl1hV 1000 700000 NN:N000 N00%W00 7000%000>JOW kM%ONO%00%OWO NN%ONO Rei xeoa xa xe.» >tee»xa rea <br /> e-5 1 _.......... . <br /> • .(.. �. ' T �Q <br /> .......................... .... ...... ........; .7; . l.l...... 1.......... ....... <br /> .......... <br /> :.r:a:::•�u:<a:nwN»wra•xene9%L'R2;'AIf:JCyl'S7?Ml 92Y R2222r 2Mt42tl R"It.Y.�.t711t"t Rs+Y we• <br /> rll 71 012 (RFV 4/8/911 ft Pane 11 <br />