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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> MDERGROUND STORAGE TANK PROGRAM FEE 'WORK <br /> F FACILITYlSITE NAME FACILITY CONTACIRAff ME N T <br /> CA L°�- C' r �bC� 4 �� E I V S D o nJ <br /> �t-YL� I <br /> L STREET ADDRESS <br /> r SITE PHONE I (WM AXre 'udw,, <br /> .� 3 b s <br /> Y CITY ' 9 Z _ '5 <br /> -�cl.� SSE ZIP CODE I of KRM%&RV10ES <br /> ONMEFVTAL HEALTH <br /> at Site <br /> A APPLICANTfI)ILLIHG NAME APPLICANT CONTACT NAME <br /> �'eC.01r <br /> � <br /> a wt c I�-v <br /> d rj <br /> [ MAILING ADDRESS APP ]CANT PHONE I {with Area Code) <br /> A <br /> C cF ! t} a 7I G - - Z,C 00.9 - — �3 <br /> N CliX_ _t Cl <br /> T <br /> STATE I CODE TYPE of APPLICATION <br /> �eS -� 535 J (Closure, Installation, etc,) l�sIka <br /> A FACILITY FEE = $100,00 each SITE ADDRESS per YEAR <br /> TDTAL <br /> C 1986 1987 1998 1989 <br /> T <br /> I too /a v <br /> V <br /> E TANK FEE = $50,00 each TANK <br /> F I Tanks off- x $50.00 1986 1981 1988 1gg <br /> A (wultipfy-i-by fee for <br /> yea <br /> e�.)� r aPnl i1:aE le) <br /> I L STATE SURCHARGE = $56.00 each TANK, (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) DU <br /> I <br /> i I Tanks o.Z z $56,00 1906 1981 1988 1939 <br /> Y (enter aoount and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90,00 each TANK <br /> S $I lanks_p2_ x $30,04 <br /> U <br /> R TEMPORARY CLOSURE (On1Y allowed ona tir.A fn, rrn f:. <br /> E <br /> SEMCO <br /> TERRY HAMILTON, PRESIDENT 14 4 3 # <br /> P RICHARD C- HAMILTON, V.P. <br /> L } PH. 209-524-9653 <br /> A " 431 W. HATCH ROAD - I 19,_ 90-1314/12111 <br /> NMQDESTO, CA 953511 <br /> II O REE R THE _- 1 e_ _ 'Lk) "' �I�L/ /P� i <br /> O Of �--` - _- _/"� 11��' <br /> R <br /> E „ � - - - _ - -_ - -—v—/� -} - - �u�4'-u-- l-A'b `_I7 O L L A R 5 <br /> ``} ��� <br /> P 4 UNION SAFE 1'p <br /> A � ' DEPOSIT <br /> DANK <br /> ! 1 <br /> D 1, 4600 Broatlway,Salida,CA 85..'16@ . <br /> $ <br /> QFFFCi' USE ONiY TOTAL DUE <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK IICASH RCVD BY DATE RECEIVED PERMIT I <br /> 11 llv t64c:2°O' I69a� /qu <br /> 4 !H .-fM•,4n ,..Ir t i1 ••IYrR'"If. <br /> F 1 , tI.,y.-!1l rA7 :'i9 it-, kY Sff- 7`1 �sAP�-1 tFOrn• 1 i.i:' 1 <br /> .' , <br />