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N JOAOUIN COUIITT PUBLIC HEALTH SERVICES <br /> ENVIRONMENTAL HEALTH DIVISION <br /> .� UN GROUND STORAGE TANK PROGRAM - FEE UORKSNEET <br /> A us <br /> F <br /> ACILITY SITE NAME FACILITY CONTACT NAME <br /> A - PAYMENT <br /> C <br /> 1 ADDRESS SITE PHONE 0 with A A C E <br /> a aOCT 0 2 1992 <br /> TITY STATE ZIP CODE ,f of 1ANTAN JOAQUIN COUNTY <br /> T �d D at SITI+UBLIC HEALTH SERVICES <br /> A APPLICANT/BILLING NAME APPLICANT CO A AH <br /> P <br /> A F vF EfdYe .4.1 <br /> I MAILING ADDRESS AP L[CAN0iPHONE 41 WITH AREA CODE <br /> CA z � 645? —z6 <br /> N CITY STATE ZIP CODE TYPE of APPLICATION <br /> T CLOSURE, INSTALLATION, etc. <br /> A TOTAL <br /> C 1986 1987 1 1988 1969 1990 <br /> T ANNUALFACILITY FEE (Prior to January I, 1991) St00.00 <br /> (It /GAS /tCA 9R7 Teo Zm s <br /> E TANK FEE • 550.00/TANK (prior to January 1,1991) 6170/TANK (after January 1, 1991) <br /> F I Tanks ( 1986 1987 1988 1989 1990 1991 1992 1997 1994 1995 1996 <br /> A (multiply O byby fee for <br /> each year app!kohl e) - 0 lzo /nd <br /> L STATE SURCHARGE • 556.00 each TANK (Due every 5 years) See Callfernla N S 5 Code, Section 25287 <br /> 1 <br /> T s Tanka z 556.00 1986 through 1990 1991 through 1996 <br /> T (enter amotnt end year) <br /> PERMANENT CLOSURE (Remove( or Authorized Ctasure-ln-Place) TANK I.D. M(s) <br /> C <br /> L CLOSURE FEE = $53.00 per hour (3 hours minimum per TANK) I TANK(s)J` K !159.00 • S <br /> 0 <br /> S <br /> U TEMPORARY CLOSURE (A one-time permit, for review I Inspections TANK I.D. ft(s) <br /> R <br /> E T <br /> EP <br /> ELEANOR W. THOMAS 6314 <br /> 303 LOUIE AVENUE 369-2675 LODI, CALIF. 95240 C�19 <br /> S <br /> rAYTOTHF. <br /> 71 ORDER OFWj /�7-P <br /> JAa �m . DOLLARS�� FARMERS & �E a MERCHANTS <br /> ��yy-- IIII BANKSea€CAm s. 5 <br /> M C MEMO/an. 1� VAR ✓' �7 •/0 -�- <br /> - . - vY <br /> 5 <br /> C <br /> TOTAL DUE s ,,RRZ <br /> OFFICE USE ONLY <br /> ww.�w.w�ww��.ww�wlM,r N14,«MN:YM FN:r'MtY.W.iTW�:M�NY�:Mpu:RMMM'��tlu WP'O:J%%SNS!W%��tllfM.n�••••••••••.V.�ITM••-••••••_........ .._ _...._..................- <br /> �tl€FAs°3" cc'�d'r�'' °�['(S�cobs'"" T.bisr Yc'��"T ""�Ii'L 3`II"r"R[��:"--CUE2(1 �`%c;i5�` '`kc�,B.,•aY,� �'�E'��(�iEB""5�'a�r7 x,�' ' . <br /> W� ._0Z.... 0 5.1.`7 ?; .000 <br /> waraor ld r.s maaasm P]Y] - vw _.•"-:'w"iie`eRi,«1;:euroiwix:Yii%:=i asv:Rira�i«�:i.::vi':'erica:z'ru:«:.,.::�aiw ir��:::: r:• .�:���:�. <br /> -NT]:S:]T.a ^^.i2::1:Y.YA.::Y.M.Y R'.Y.t:':Y:�.^.:!:Y: Y^.`::%::.^,Y••••L:'•YCYl.^1T T]:�t+lq�AJU YS M aY K�Y�IfM M M na'.r,aS Y/ <br /> Yv 71 n17 rec, ",7A/901 ft • Pnow 11 - <br />