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0IMDERBROIR@ STORAGE TANK PROGRAM - FEE WORKS y <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> T KBTS Luther Russell <br /> L STREET ADDRESS 9901 Woodward Road, Ripon, CA SITE PHONE 1 (with Area Code) <br /> Tq?.1-3897 <br /> Y CITY STATE ZIP CODE f of TANKS <br /> Manteca I CA at Site 2 <br /> FAPPLICANTAILLING NAME PAYMENT APPLthNO Ae Eer <br /> P RECEIVED <br /> L <br /> AMAILING ADDRESS 13515 Marengo RoadJUN 2� �r '' APP112 1) Pe 13�6� Area Code) <br /> N CITY Galt ENV)R�NMENTA S _ `�u3$E l TYPE of APPIICAiION Tank Removal <br /> - <br /> (CIO <br /> M� Icro� 9 Z (Closure, Installation, etc,) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> T 1986 1981 1988 1989 <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks Tia $50.00 1986 1981 1988 1989 <br /> A leultipiy-1-by fee for <br /> T each year applicable) <br /> ( STATE SURCHARGE = $56.00 each TANK (see CA HEALTH f SAFETY CODE Sec 25281 for applicability) <br /> T 1 Tanks a 156.00 1986 1901 1988 1989 <br /> Y (enter iiount and year) <br /> J. <br /> f <br /> CPERMANENT CLOSURE (Reeoval or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ $90.00 each TANK 1 Tanks ? a (90,00 f 180.00 <br /> RICH- MART _ <br /> JIM THORPE, DISTRIBUTOR OF QUALITY PRODUCTS <br /> 368-6175 462-4581 10407 <br /> 351 NO. BECKMAN ROAD, P,O, BOX 357 <br /> LODI, CA 95241-0357 <br /> i '-IAL <br /> PAY r� <br /> TOTHE �/� c� 90-103/1211 <br /> s oscour,r ORDER OF 79�J <br /> y <br /> Lo 1OEEICE OLLARS <br /> 1Z W,Walnot St,Lodi,CA 952M <br /> Zee <br /> OFFICE USE ONLY <br /> SNEEPS 1 COMP 1 LOCCODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVO BY DATE RECEIVED PERMIT 1 <br /> /9f 3 1' nWor 9 CODE <br /> *tea _SED" I <br /> a <br />