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-. ...--- unl✓•enuunu QIUAAUL IMA rRUUNUI ILL RUAAOALLI �I <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME • . rZ6aj @C S JR O <br /> r <br /> _P•�r �' IT 1 cK` i? c;6er'r 34relie i <br /> L STREET ADDRESS t;, li SITE PHONE 1 MIT" ARRA COOK,, <br /> Frio <br /> Y CITY STAT IIP CODE 1 of Tanks <br /> A I6co at Site 7 <br /> F APPLICANWILLIN5NAME -k ) APPLICANT CONTACT NAME <br /> i K`�= 15 � . �lAe. <br /> � <br /> 1 MAILING ADDRESS ( - o APPLICANT PHONE I MITH AREA CaOC <br /> N CITY , j S]A1 IIP CODE TYPE of APPLICATION ,Rcwtp 1/41- <br /> M / CLOSURE. IMETALLATION. ETC.. <br /> IS <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C y 1386 f 1387 1988 191983 <br /> E TANK FEE _ $50.00 each TANK C " <br /> F 1 Tanks _ _ 1 150.00 1386 1387, ,1988 1903 1 s <br /> A Iwltiply 1 by lee for <br /> C each year applicable) 411RRF. I1'i P ti t y %. <br /> I — F <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> 1 1 Tanks 1 $56.00 1386 1387 •' I <br /> ^ 1"1988 !` 1383 _ <br /> Y (enter Tank mount and year) -' <br /> 1 • 11- It I^Inv la ! . <br /> $ <br /> r, PERMANENT CLOSURE (Removal or Closure-in-plate) I.1-�" ` • ' i' <br /> L ------ — <br /> 0 CLOSURE FEE = $30.00 each TANK 1 Tanks_:_7. 1 190.00 <br /> S -- <br /> BANK OF AMERICA RrAe• y p� 19450 <br /> <br /> <br /> R.o. eoS RAE 1783 NORTH CORRAL HOLLOW <br /> TRACY. CA esa1. <br /> TRACY, CALIFORNIA 83978 <br /> TELEPHONE 893-8280 TRACY <br /> PAY DATE f/Iccico ��. <br /> TO THE <br /> OBOE IT GT R & B & SONS. INC. <br /> • 1 LTCICX <br /> 7 <br /> <br /> TOTAL DUE S F3(y, a <br /> OFFICE USE ONLY <br /> I <br />} SUEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD NECK ASH RCVD AY DATE RECEIVED PERMIT 1 <br /> v <br />