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_ UNURGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F F/CILIIY;—el NAAE —'- FACILIIY CONTACT NAME <br /> S <br /> Pure9ro Company Areo <br /> I STREET ADDRESS SITE PHONE I Ivlth Are1 Coda) <br /> II 1904 W Charter Way (209) 466-2041 <br /> YICIIY SI E iIP CODE 1 of TANK'S <br /> StocktAA APS PIIQANIId LLINIi�NA11E �� APF�f•ANTICONIAL'T NAME --�—� <br /> IF, <br /> same - — —� <br /> IINAILING ADDRESS APPLICANI PHONE I (vith Area CodvI <br /> CI <br /> I" tfY <br /> STATE IIP CODE TYPF. al APPLICATION Tank Removal <br /> Kiwiye, Installation, Ac.) - <br /> t � 1 <br /> I FACILITi Rt 11'0.00 Pilch SITE ADDRESS per YEAR — - - TOTAL <br /> A,:'I 1986 1981 <br /> _27- <br /> 38 19Q9 j_ — I <br /> LITANK FEE = 151J.00 ea(h TANK <br /> F�/ Tanks _ i 156.00 1986 1387 TI��1388 1333 <br /> -!AI <br /> yea <br /> nultlyki I by fee for -•-- ==--I-'-_ � <br /> i 1� I cfi r apfluablel <br /> ILISIATT. SURCHARGE % $56.00 RA..h TANK Ilea CA HEALTH L SAFETY CODE Sec 25181 for applicability) -- <br /> 11 1 Tank,_ _ _ r 156.00 r 1306 1 1381 J988 198 <br /> kdtealer ailuro) and year - ^— <br /> __ <br /> I <br /> IrCIPrRMANENI CLOSURE (Removal or Closure In play ) <br /> OICLQSURE FEE - 190.00 ea.-h fANk t.eu• 7 + LOA All �• fan nn <br /> x�.EIK <br /> DATE«.... M.MOUNT RICH-MART 10498 <br /> JIM THORPE, DISTRIBUTOR OF QUALITY PRODUCTS <br /> P.O. BOX 357 368-6175 4624681 <br /> 351 N. BECKMAN ROAD OD84UMI <br /> LODI. CA 85241-0357 1 D <br /> PAY <br /> ORD�HE pF i /O <br /> tv DOLLARS <br /> TOTAL OF INVOICES - <br /> EE` �GIECOUNT FARMERS a <br /> LEW MERCHANTS - <br /> TOTAL OEUVCTIONS BANK E�Sf5A11Y <br /> MMOJNT OF CHECK <br /> TOTAL DITE I <br /> OfF(IE USE 011(y <br /> k`. i 5 4 Ir,OHP t DOC CODE DISI LODE AMOUNT pUE TA"OUNT7- <br /> SN R0 /Y DATE RECEIVED PERMIT <br /> C -- -� <br /> N /is 7y pVRE ri 3L y <br /> I. ,I <br />