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TF <br /> SAN AQUIN LOCAL HEALTH [FI ICT <br /> --- GROUND STORAGE TANK PROGRAM - FEE WORKSHEET 1_ <br /> FACILITY/SI IE NAME FACILITY CONTACT NAME <br /> 1 � 12 <br /> Lell <br /> STREET ADDRESS SITE PROM 1 N T" .tt. C069 <br /> I So <br /> Y CITY.-r- S A1E IIP CODE 1 of Tanks <br /> 1 �_ _ _ __ k- at Site <br /> F APPLICANT/-BILLI96 NAME APPLICANT CONTACT NAME <br /> 1 MA ING ADDRESS APPLICANT PHONE 1 NIT" •Nt4 CODE <br /> c <br /> OION <br /> N Clir� —�STATE iIP'CODE APPLICAT <br /> LlCLY INtT.LION , ETC. <br /> FACILITY FEE t 11/00.00 each SITE per YEAR TOTAL <br /> A —---- _ <br /> C 1906 198] 1988 1983 <br /> I <br /> E TANK FEE C 150.00 each TANK <br /> 1 Tanks 1 150600 1986 1381 nw— <br /> f83A (multiply-I�by lee for C each year applicable) <br /> L STATE SURCHARGE a 456.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25281 for applicability) <br /> I _— _ <br /> 1 I Tanks 1 156.00 R19A6 138] 1388 1383 <br /> Y (enter iiiiit and year) — — <br /> C <br /> PERMANENT CLOSURE (Removal or Closure-in-place) —�— — <br /> 0 CLOSURE FEE = 130.00 each TANK 1 Tanks �_ 1 130.00 1 <br /> S _`— ---- <br /> CRISP TANK TESTINQ 18 01 <br /> P.O. 13OX 30487 891-1828 <br /> STOCKTON, CA 85213- <br /> Y <br /> --L3007/1211 <br /> PA19L0 <br /> TO E <br /> OR RO <br /> Xx $?/�Q .00 --- <br /> LLARS <br /> Thlrley r.0.awl 0700 --- <br /> 10ti <br /> ' mme►wt,c.ur tate — <br /> :, <br /> FOR. <br /> MAL NYC T 1 _ <br /> Dirrct alt oNtr U <br /> SWEEPS 1 COMP 1 LOC CODE DISI CODE AMOUIIT DUE AMOUNT RCVD CHECK I/CASH RCVD DY GATE RECEIVED PERMIT 1 <br /> , 1 <br />