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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE NOR T <br /> F FACILITY/SITE NAME FACILITY CONTACftRky M E N Tp <br /> LA. Me T—' f}s50C( <t�C �il��E�t rLEc /�o i <br /> L STREET ADDRESS SITE PHONE I NMAYrel o W B 1 <br /> T 5 3 6 5 9 2 V - 65 <br /> Y CITY 5�-�c >J S TE ZIP CODE 1 of ROWENTAL HEALTH <br /> at Site pERMIERVICES <br /> ECI <br /> ICANT/BILLING NAME APPLICANT(CONTACTINAME ' I <br /> Se4h CU �IC�hA v C{ 14aY ,L 1+0(1) <br /> LA�RESS g J G APP (CANT PHONE t (with Area Code) <br /> a 7 �3 <br /> _ _l�S�� STATE Z CODE TYPE of APPLICATION <br /> �/� $3C / (Closure, Installation, etc.) Cldsi ae- <br /> ETANKFEE <br /> = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> 1986 1981 1988 1989 <br /> loo /oo too la0 ; tFpU <br /> 50.00 each TANK <br /> F t Tanks ox (50.00 1986 1987 1988 193'3 <br /> A (multiply-11-by fee for <br /> e3ih yeir 3pplh:ahle) X00 OU <br /> L STATE SURCHARGE = $56.00 each TANK, (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T t Tanks A x $56.00 1986 1987 I`i88 t989 <br /> Y (enter ioount and year) <br /> //a <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE _ <br /> 5 $90.00 each TANK 1 Tanks_CZ_ x $90.00 ; /e o <br /> U — <br /> R TEMPORARY CLOSURE (Only allowed nna ti,, FA. <br /> SEMCo <br /> 1443 $ <br /> TERRY HAMILTON, PRESIDENT <br /> RICHARD C. HAMILTON, V.P. _ <br /> L PH. 209-524-9653 <br /> A '! 431 W. HATCH ROAD L��\) - I 19 EI E A 90-1311/4/11211 <br /> N 111, PAY TO THE <br /> DESTO• CA 95351 <br /> 0l ORDER OF_�;_t <br /> E <br /> ;( —UNION SAFE —lJ O L L A R 5 <br /> A DEPOSIT <br /> R I SRP 4soo eroee..r,seneeDcAn e�s��ea � � - <br /> $ Q 2 <br /> OFFICE USE ONLY TOTAL DUE <br /> SWEEPS t COMP I LOC CODE DIST CODEHAMOUNTDUEMOUNT RCVD CHECK 1/CASH RCVO BY DATE RECEIVED PERMIT 1 <br /> 2o9a� )q 3�w,} .7FUU27770E .1 r ;+...... i PPW e.. <br /> .; rg <br /> iy-.�..IPryln'i .... : tl::.!11 IFS i'f+l L4�'pM1PA! v <br /> �.7N.M �A�i i.�t <br />