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ICES - <br /> SAN JD110UIN ICOUNTY INOERl7tQI1N)1 STORAGENTANKVPROGRAM - FEONMHEALTH DIVSION <br /> UORKSMEET <br /> S FACILITY SITE RVE FACILITY CONTACT NAME <br /> SITE PHONE 0 with AREA CODE <br /> FACILITY ADDRESS J <br /> d, , c, eL STATE ZIP CODE M of TANKS <br /> A <br /> LITY`S-60 C 1\�I _ �e at SITE I <br /> `t <br /> P APPLICANT CONTACT NAME <br /> P APPLICANT/BILLING NAME <br /> L <br /> I APPLICANT PHONE 0 WITH AREA CODE <br /> C MAILING ADDRESS <br /> A <br /> N STATE ZIP CODE TYPE of APPLICATION <br /> T CITY (Closure, Installation, etc.) <br /> nuk <br /> r/� �I _ (f/},, <br /> ` CGO Q 1986 1987 1988 1989 1990 <br /> ANNUAL FACILITY FEE (Prior to J ry 1, 1991) $100.00 xxxx xxxx f <br /> A <br /> Lxxxx xxxx 5 <br /> T FACILITY PENALTY FEES ASSESSED (if Applicable) <br /> I5170/TANK (After January 1 9 1 <br /> V TANK FEE = 550.00/TANK (Prior to January 1,1991) <br /> E R Tanks 1986 1987 1988 1989 1990 1991 1992 1993 199 <br /> F (nultiPlY i-67-fee for 5 <br /> A each year applicable) xxxx xxxx <br /> L V GQ )IgTY <br /> I TANK PENALTY FEES ASSESSED xxxx xxxx <br /> L Pl9B� iH UIVIoION <br /> 1 STATE SURCHARGE - s56.00 each TANK (Due every 5 years) See California H d, S Code, S L24iIfifLiF r <br /> T1988 through 199D 1991 thr <br /> 0 Tanks— x 556.00 <br /> (Enter as Tnt and year) 5 <br /> TANK I.D. 0(s) _ <br /> C PERMANENT CLOSURE (Removd'or uth6ri2ed'.Claeures Ifia Pthee)' �.- <br /> L i?TANKCi�r*^^'r"""i(','f23ioD • 5 �� -'� <br /> O CLOSURE FEE 578.00/hour (3 hour minimum/TANK) <br /> I [.++.—� - <br /> STANK I.D. 0(s) <br /> U TEMPORARY CLOSURE (Plan Review A inspections) - <br /> R ... ev`owit <br /> E TEMPORARY CLOSURE FEE : 578.00/hour (3 hours minlmlANFACILITY) S23 nilnw- <br /> _ E <br /> 8248 <br /> INC. <br /> <br /> 1 W0 E.CHANNEL ST. FIRST INTERSIAIE BANK OF CALIFORNIA 0695 <br /> STOCKTON,CA 95205 4932 PACIFIC AVENUE STOCKTON,CA 95207 <br /> iECK <br /> (209)943-7337 d---rl QRS C AMOUNT.. <br /> tH� CHECK <br /> NUMBER <br /> PAY r'� DESCRIPTION <br /> AMOUNT (J_ t r-F <br /> OF HE ORDER OF <br /> DAZE MF . I C. <br /> mz <br /> ION CHE I <br /> ium <br /> ---_-- /� u- sus+" <br /> -- l <br /> � <br /> R/CASH RECEIVED BY I DATE RECEIVED <br /> 6, <br /> 5:1144.aV!!,tlli!!ii4!II,A I!Iuvfi14J41i1W':t: '" '41i1Mmmi W:!I IJ6ti.uvW�.a.Lid lbvi - -R <br /> . T m_.:!:_ -......,W.ap:bPIAP_=:u2Zp^�-ti:3i&. .:oda➢L3:!6Pu <br /> Ell 23 032 (REVISED 10.28-93) <br />