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n vrnu v vn 1\IS IIIVV11I111 <br /> i A FACILITY/SITE NANE FACILITY CONTAC ME <br /> table <br /> C Equi Life- e Road Ranch a Judd <br /> 1 <br /> L SIAEET ADDRESS25499E. Shelto odd SITE PHONE 1 (with Area Code) <br /> T (209) 887-3556 <br /> Y CITY Linden STATE IIP CODE 1 of TANKS <br /> CA at Site 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> F <br /> IP Equitable Life — Equitable Agri Business William K. Irish <br /> I MAILING ADDRESS APPLICANT PHONE 1 (with Area Code) <br /> n 2700 Ygnacia Valley Road, Suite 315 (4 15) 935-9172 <br /> N CITY Walnut Creek STATE IIP CODE TYPE of APPLICATION Tank RemoVal <br /> CA 94598 (Closure, Installation, etc.) <br /> A FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 CJQ <br /> T <br /> I 7de' Qo f <br /> E TANK FEE _ $50.00 each TANK <br /> F t Tanks f '1 f50.00 1986 1981 1988 1989 p <br /> A (multipTy 1-by (ee for <br /> C each year applicable) gof oD <br /> f <br /> L STATE SURCHARGE = $56,00 each TANK (see CA HEALTH IF SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks__ 7_ x 156.00 1986 1987 1988 1989 <br /> Y (enter amount and year) <br /> f <br /> C PEP.MANENT CLOSURE (Removal or Closure-in-place) — <br /> 0 CLOSURF FFF - wn <br /> 10660 <br /> RICH MART <br /> ___-_ -- -- - JIM THORPE DISTRIBUTOR OF QUALITY PRODUCTS <br /> 366-6175 462-4561 �fp IGM211 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 <br /> LODI. CA 85241-0357 <br /> ---- _._ PAY -� $ 9J1 <br /> TO THE <br /> ORDER OF F- -- <br /> os� - ---DOLLARS <br /> �CE <br /> W. 5l.,Lo I.CA 9520 <br /> FEE _ 135.001hrl FEE = !35.00/4 f <br /> TOTAL DUE f (4kup_,A) <br /> OFFICE USE OKTy <br /> SWEEPS- COMI LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CNECK 1 SH RCVD BY DATE RECEIVED PERMIT 1 <br /> Zo 16G» Fi (,o4 i <br /> ti (} <br /> L [ a <br />