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BAN JOAQUIN LOCAL HEALTH DISTRICT <br /> GDEROROUND STORAGE TANK PROGRAM - FEE NORKSO <br /> .ACILITYISIIE NAME FACILITY CONTACT NAME <br /> ' A <br /> C Robert Brayton <br /> IL SIREEI ADDRESS SITE PHONE 1 (with Area Code) <br /> 1 (209) §3B--Z388 <br /> 1745 gpicand St.T <br /> Y CITY SIATE 11P EE 1 of ANK'9 <br /> Escalon, Calif-. ��320 at ite 1 <br /> A APPLICANUBILLING NAME APPLICAN <br /> P <br /> P Brayton and Sons Inc. Robert Brayton <br /> L <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> C 838— 7388 <br /> A PO Rny 95 <br /> T CITY STATE 11P CODE TYPE of APPLICATION Closure <br /> Escalon Calif. 95320 (Closure, Installation, <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> I <br /> 1 � 1 <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanks x 150.00 1 6 1981 1988 1989 <br /> A (multiply-1-by fee for <br /> jeach year applicable) 1 <br /> `�(v f STATE SURCHARGE = 156.00 each TANK (see CA EALTH I SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks_____ x 156.00 1986 1981 1988 1989 <br /> Y (enter amount and year) <br /> f <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> O CLOSURE FEE = / ##)each TANK $53.00/ hr./3hr in. 1 Tanks__/__ x 19�c00Xx $ 159.00 f 159.00 <br /> S <br /> R TEMPORARY CLOSURESOniv_allnund�--r-i-- <br /> RICH-MART 11000 <br /> ON MC.O�IOWINY pCCOVlrtM1 <br /> JIM THORPE. DISTRIBUTOR OF QUALITY PRODUCTS <br /> 388-8175 482-4581 <br /> 351 NO. BECKMAN ROAD, P.O. 150X 957 �OD100/1271 <br /> LODI, CA 95241-0357 <br /> PAY <br /> TO THE <br />! TOTAL ORDER ` OU DOLLARS <br /> 5 oiecouNT <br /> 6 <br /> AMOUNT OF CNCC1t R <br /> Batk �� L• <br /> LOOI OFFICE <br /> I"W.W.1-1 51.,LSI,CA 95119 <br /> 4N— <br /> - - I IUTAL UUt 11159.00 <br /> OFFICE USE ONLY <br /> ZWEEPS COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUIIi RCVD CHECK tICASH RCVD BY DATE RECEIVED PERMIT 1 <br /> lar-r (� v �J5 /�� 2 Z <br /> 0-S �� <br />