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JUL_ - 26 - 99 WED 1_4 1 MOIRE PETROLEUM P qS <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM -..FEE MORKSHEET^-— — <br /> F FACILITY/SITE NAME — -+ FACILITY CONTACT NAME <br /> C FWe4NrcS E )Oro7V sry �cIZ Z F cv Zt <br /> L STREET ADDRESS ' — SITE PHONE 1 NrrN •ema eomm . <br /> I iy80o c,1. �av�u xKrE 0- 20 239 -771 .7 <br /> T --- �— . <br /> Y CITY STAT 7LP CODE 1 of Tanks <br /> M4ry�c ,4_ GA X15 33G✓ at Site — <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> P Y"L^ORF?L LG0.-1 _ J�9-P-y w`0o12� <br /> L _.- <br /> ---- -- __.—__---- —'_ _ <br /> I MAILING ADDRESS APPLICANT PHONE 1 Nr^' "'e• eeee <br /> C P.c�. v�L��_. .__— _.----F•_ _ Zo2B� 5 27tO --- ---- <br /> N CITY - -- ---_ -- -_-- STAT jjP'COOE TYPE of APPLICATION ^- - <br /> T 5/q-rvT/� G 4 Cys 35o c�e•�•ml IMe TAllAr 10N, [TC. �G yb✓�� <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A - - _ .._ -_—_ __.. __ -.. -- ....... <br /> y .._...---__.... <br /> -1987 _ • � 1988 1989�--.-t_--�-- <br /> E TANK FEE a 150,00 each TANK <br /> F 1 Tanks _- 1 150.00 1986 1987 1988 1989 <br /> 1-b <br /> A (multiply y fee for - __ <br /> C tacN year applicable) 1 -� <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25187 for applicability) <br /> T 1 Tanks 1 156.00 1986 1987 1988 1989 <br /> Y (enter Timet and year) --- - - <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE ■ 190.00 each TANK 1 Tanki 1 1^,0.00 <br /> 5 — <br /> U - -- -- -- --- ----- - ---------- <br /> - - -- ---- -------- <br /> P. TEMPI <br /> E -- <br /> Ili—IN <br /> �I ?41250 <br /> MOOREPETROLEUM WELLS FARGO BANK 1210161 <br /> P PLAN 1 120 K STREET <br /> L ,•„ BOX 67• BANTA,CALIFORNIA 95304 MODESTO,CA.95354 005156 <br /> N PUN <br /> REPAI / lNy ' c u AMOUNT <br /> R TANK f <br /> E PAY TO THE /�L <br /> AF .- - ORDER OF !!! T ` ^ / <br /> PIt <br /> I -- MOORE PETROLEUM <br /> R UNAUI <br /> (vhel <br /> FEE <br /> no u• <br /> nIFa�fuK.'P.'l� �ASiJ��I@9PI I�JT+I�hB a": <br /> SWEEPS 1 COMP I LOC CODE DI CODE AMOUNT DUE AMOUNT RCVD CHECK 11CASH KCVO BY DATE RECEIVED PERMIT 1 <br /> 270 7P 27/1 7r ._ .. ----- <br />