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UN OUNO STORAGE TANK PROGRAM TEE NI- -1--ET <br /> ------ - - (FACILITY CONTACT NAME <br /> J�iFIFACILITY/SITE NAME ' /// ? �/ - Sg4�ytC%> //,1C' <br /> SIG 2 l� /E I Fi I c+� ) <br /> Y ' L <br /> j4 ,V�I�—�(t./_S_.—. Y_H. -.Ol ........_._...._.._....__.__..__...__...._-.__.-.._ NI T" ARCA CODE —_— <br /> I - SITE PHONE 1 <br /> L STREET ADDRESS <br /> Y CITY STATE 7IP COOS I of Tanks <br /> at Site <br /> APPLICANT CONTACT NAME �lr� �$S,GI► <br /> A APPLICANT/DILL NG HARE CAT J FtGK � rGJ. <br /> P 1✓E.JTZRN MG'`(m S <br /> P --- ..__..._� - <br /> L ..._...._._._._......._... WITH AR_A CODE <br /> ---"`-"- -----'-�-� APPLIf,ANT PHONE 1 N' ` <br /> I HAILING AOORES9 <br /> N CITY �STAT*,-"'-' <br /> 11P CODE 'i PE APPLICATION ✓���� - <br /> CLC RIIR RE E, Ing TALIni ICA, <br /> i <br /> -- �---- TOTAL <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR -- <br /> 1996 I3d7 1399 1393 _ <br /> - <br /> II - . f-.................. .......L...._.........-- ._...�._.... ---------- -- - -- -$- - ------I <br /> IE TANK FEE _ $50.00 each TANK <br /> ---- - -- - <br /> FII Tanks x 150.00 1396 l 7 94 1993 -- — <br /> A (sultipTy ( hy lee (or <br /> C each yearapOluablz) - - l- - -- <br /> l <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH I, SAFETY CODE Sec 25197 for applica <br /> T 1 Tanks__ x Si6.Oi1 ('396 f (' ll 1 _...____ ._... <br /> Y (enter asount and year) <br /> ENVIRONME TFaL HEALTH <br /> — -- --�-- - --.......----...... ........_.........._-.._........ _ - -- -PERMIT) ES--- <br /> —..-._... __..._.. ...._........ _ _............. -- <br /> C PERMANENT CLOSURE (Reuval or Closure-in-place) 8 F-Pn of L <br /> 0 CLOSURE FEE = S10,00 each TANK J i Tanks__ x $90.00 S {��_U 0- <br /> O --- <br /> DATE INVOICE AMOUNT <br /> <br /> 2735 TEEPEE DR. SUITE E <br /> STOCKTON.CA 95205 9748 <br /> (209)948-6124 <br /> I <br /> PAYO � F/6147y N!V/e" DOLLARS <br /> aR SS AwA DISCOUNT CHECK AA10l1NT_. <br /> DATE TO THE ORDER OF oiweR cCie.Ynrnw�E <br /> WESTERN METER S VICE, INC. <br /> UNION SAFE DEPOSIT BANK <br /> STOCKTON,CALIFORNIA <br /> Yl(ILC VJt Vll li — <br /> °. ' �Pi88�1.�8!1m918� 1!3f8u"�12�!1�1��12RIIfR1C9�G0G�IIVu�IPa�'VOF'�IIVIIIp�IiU�III�!�IIN�)11GNIIII!GiGIli1�191iG1'I!9118!IlGiiidlli!�'�df�wlCllliNVflill��liCI�IG01Cllfl�lil!IIGIIiJulluli0l'il!I]lIV'fG!1M�1a191'Iiil�Ci!IVI'SHill <br /> SNEEPS 1 LOMP 1 LOC CODE�DIST CODE AMOUNT DUE AMOUNT RCVD NEC( 11CASH RC'!D 9Y DPT: PECEIYED PERhIT I <br /> / � // / E� n. 111°� tp 11M1ir ill IA X121 II I ,,Ip9' ryrl�j�IIII�iI1�1���III�1q.I�II�X'IyGilluill iGlllrn Fiml!1"I°��n. IP PSI. wa.7 L`aRm.. lizG'�Ii <br /> 1 mi'n &�oa-ILULC��.°'.I116i ll,dl .,. <br />