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BAN JeQUIN LOCAL HEALTH DISI•CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE NORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C �bL) 11) 1 -�L �>=A?AlA-AJD > � �LIt211 <br /> ISITE PHONE 1 (with Area Code) <br /> L STREET ADDRESS Loc-us <br /> I � <br /> T STATE ZIP CODE 1 of TANK'S <br /> Y CITY I D D �� ` C 9S2 I O at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P L- G )zn) aVJ va [- � L- IIl4 ���I� dNI�? D <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C 39 , 0 L-1V`V\ ' RIL14 zP Zog -33 . -3�5-D <br /> A <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T Qc l% yv, PCS oil q52,Zp (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> I $ U <br /> � 5 o ISG I sv <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks x $50.00 1986 1987 1988 1989 <br /> A (eultipTy_I-by fee for $ �_ <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> T I Tanks____ x $56.00 1986 1987 1988 1989 <br /> Y (enter aaaunt and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L - - - - - - - - - - - - - - - <br /> 0 $ d <br /> � FERNANDO PEREIRA 7-83 <br /> 1252 <br /> 2 STELLA PEREIRA <br /> E 3910 CALIMYRNA ROAD 333-2046 $ <br /> ACAMPO, CA 95220 _2 <br /> P m Pay to th ,� <br /> L ; Orderof — <br /> Aa <br /> t( z Mllar5 <br /> BANKOF ON ` <br /> R •� LOW OFFICE9�fE t30W.Walnut SL,1 A � <br /> A For <br /> I <br /> R <br /> (when applicable) INSPECTION INSPECTION <br /> FEE _ $30.00/hr FEE = $35.00/hr FEE = $35.00/hr $ <br /> TOTAL DUE $ <br /> OFFICE USE ONLY <br /> SNEEPS 1 COMP 1 LOC COBE DIST CODE AMOUNT DUE AMOUNT RCVD CHECI)/CASH RIND BY DATE RECEIVED PERMIT 1 <br />