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SANQUIN LOCAL HEALTH DIST T <br /> GROUND STORAGE TANK PROGRAM - FEE WORKSHEE <br /> F FACILITY/SITE NAME FACIIITY CONTACT NAME <br /> A <br /> C NOR—MAC, INC. Don <br /> I <br /> L STREET ADDRESS 6215 Tam O'Shanter SITE PHONE 1 (with Area Code) <br /> 1 (209) 957-9170 <br /> T <br /> Y CITYT TE 21P CODE 1 of TANK'S <br /> Stockton, at Site 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P NOR-MAC, INC. Peter Voskes , Operations Manager <br /> P <br /> I MAILING ADD SS APPLICANT PHONE 1 (with Area Code) <br /> C 0. Box 214097 916 482-2924 <br /> ASTATE TlP CODE TYPE of APPLICATION Tank <br /> N CITY T Sacramento, CA 95821 (Closure, Installation, etc.) Removal <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 19A6 1981 1988 1989 <br /> T <br /> 1 AY s <br /> v r <br /> E TANK FEE = $50,00 each TANK 'v <br /> F i Tanks z 150.00 1986 1987 1988 1989 <br /> A (multiply-T-by fee tar <br /> C each year applicable) �^ f <br /> I q/ N <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicatii� <br /> I <br /> T 1 Tanks x $56.00 1986 1987 1988 1989 <br /> Y (enter iiount and year) <br /> f <br /> CLOSURE (Removal or Closure-in-place) <br /> ICIFERKANEXT <br /> 61CLOSURE FEE _ $90.00 each TANK _ lTanks__1__ It $90.00 f 90. 00 <br /> o .iEF RICH - MART 10395 <br /> —I JIM THORPE, DISTRIBUTOR OF QUALITY PRODUCTS <br /> 368-6175 462-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 9(}103/1211 <br /> LODI, CA 95241-0357 y <br /> PAD <br /> *ornL TO THE <br /> j ORDER O <br /> AMOUNT 01 <br /> N 0 <br /> DOLLARS <br /> Bank wdson <br /> WDIOFFICE <br /> 40 W.Walnm L.,Lod.,U 9510 <br /> -------- TOTAL DUE IS ICY <br /> OFFICE USE ONLY <br /> SWEEPS 1 COUP I LOC CODDE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK CASH RCVD BY DATE RECEIVE- PERMIT 1 <br /> 12 7/1�pZ <br /> i tl <br />