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Sn JUAQUIN LOCAL HEALTLI E IRICT <br />Now <br />STORAGE TANK PROGRAM - FEE WORKSHEET <br />FFACILITY/SITE NAME <br />FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br />_ <br />TOTAL <br />FACILITY CONTACT NAME <br />— <br />7 1986 <br />1981 <br />1988 <br />CBest <br />1 <br />Cleaners <br />Kyo S. Pang <br />L STREET ADDRESS <br />541 N. Hutchins <br />— <br />SITE PHONE 1 (with Area Code) <br />1 <br />r <br />E <br />— <br />TANK FEE - 150.00 each TANK <br />(209) 369-2865 <br />Y CITY <br />Lodi, <br />1987 <br />fIF�CQUE <br />1989 <br />1 of TANK'S <br />CAATE <br />955 4400 <br />at Site 1 <br />AA APPLICANT/BILLING NAME <br />STATE SURCHAR4E = 156,00 each TANK (see CA HEALTH IF SAFETY CODE Sec .5101 for applicability) <br />APPLICANT CONTACT NAME <br />P <br />Best Cleaners <br />1987 <br />Kyo S. Pang <br />L <br />C MAILING ADDRESS <br />541 N. Hutchins <br />— - <br />APPLICANT PHONE 1 (with Area Code) <br />A <br />_ <br />—(209) 369-2865 <br />N CITY <br />T <br />STATE 71P CODE <br />TYPE of APPLICATION Tank Removal <br />Lodi <br />CA 95240 <br />(Closure, Installation, etc.) <br />A <br />FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br />_ <br />TOTAL <br />C <br />T <br />1 <br />V <br />— <br />7 1986 <br />1981 <br />1988 <br />1989 <br />— <br />f _ <br />E <br />— <br />TANK FEE - 150.00 each TANK <br />F <br />A <br />1 <br />1 Tanks 1 $50,00 <br />(multipTy'l-by fee for <br />each year applicable) <br />1986 <br />1987 <br />1988 <br />1989 <br />6 <br />STATE SURCHAR4E = 156,00 each TANK (see CA HEALTH IF SAFETY CODE Sec .5101 for applicability) <br />T <br />Y <br />1 Tanis 1 156.001986 <br />(enter iiiuIit and year) <br />1987 <br />1968 <br />1983 <br />Is <br />T CLOSURE (Removal or Closure -in-place) <br />FEE = 690.00 each TANK 1 Tankx 190,00 f 90.00 <br />RICH - MART 10466 <br />JIM THORPE. DISTRIBUTOR OF DUALITY PRODUCTS <br />368-6175 4624581 <br />351 NO. BECKMAN ROAD, P.O. BOX 357 <br />LODI, CA 05241-0357 <br />TOTAL <br />.1 ... u.T <br />AMO. NT Of CMECN <br />OFFICE USE OKIy <br />PAY <br />TO THE <br />ORDER <br />1001 OFFICE <br />110 W. Walnut S1., IW" G 952Q <br />s ep-0 <br />— -----DDOLOL <br />LARS <br />TOTAL DUE <br />COMP 1 LOC CODE DIST CODE <br />AMOUNT DUE AMOUNT RCVD CHECK 1/CASH <br />RCVO BY <br />DATE RECEIVED PERMIT 1 <br />ZI nest ' oa 3 <br />91— qo <br />�%9 �9 <br />"lba <br />