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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> NDERGROUND STORAGE TANK PROGRAM - FEE WORK L� <br /> F FACILITYISITEENNAME / _ FACILITY CONTACIRF,IIIAIEYMENTp <br /> L0. Mer r SOC( �iY—� �1 @E <br /> L STREET ADDRESS SITE PHONE I NMAre I eodVJ b <br /> T 5 3 6 mtLtn_ 54 9 Z ^ 65 <br /> Y CITY STATE IIP CODE 1 of Y�ONMENTAL HEALTH <br /> J� !h at Site ERMI�ERVICES <br /> AA APPLICANT/BILLING NAME APPLICANT rrf,ONTACT NAME1' II <br /> L S'2!M c U �IC G0-� 146LmL I+oiv <br /> I MAILING ADDRESS APP ICANT PHONE 1 (with Area Code) <br /> C �3/ U� 1�a�L� Z09 — �3 <br /> i LI es �� /py STATE I CODE TYPE of APPLICATION <br /> !! �r r�i�� / (Closure, Installation, etc.) CIDS.l12e <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1983 <br /> T <br /> I loo '/ /O o /O o / O OE $ CFdU <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F I Tanks oZ x $50,00 1986 1987 1988 133'3 <br /> A (multiply-1-by lee for <br /> C enh ys,r .pplica6le) /!�Q O /OQ /a0 OU <br /> L STATE SURCHARGE = $56.00 each TANK, (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T I Tanks A x $56.00 1386 -/ 1987 1988 1333 <br /> Y (enter 5vount and year) <br /> C =PERNANENTCLOSURERemoval or Closure-in-place) <br /> L <br /> 0 00 each TANK <br /> 5 I Tanks_ Z x $90.00 $ /�0 <br /> U <br /> R TEMPORARY CLOSURE (Only allowed nne ho. t.,. F .., ,..-..-. <br /> E <br /> SEMCO 1443 1 <br /> TERRY HAMILTON, PRESIDENT <br /> P RICHARD C. HAMILTON, V.P. Q <br /> L PH. 209-524-9653 ( 9 — 19" 99-1714A1211 <br /> /uwq <br /> A _ 431 W. HATCH ROAD <br /> N ;; M�\PAY TO DESTO, CA 95351 <br /> $ /0 9a. <br /> �)e O�ROF_THE <br /> R .lil O L L A R 5 <br /> E ^'� UNION SAFCE <br /> A �I onff7 DEPOSR <br /> A ) U DANK <br /> aero e.o.dw.y,Seim..CA M. i <br /> ( 1C 12L113LL.81 1443..._03 0674L,111011' <br /> 111 111 <br /> F <br /> TOTAL DUE $ Z <br /> OFFICE USE ONLY <br /> m p <br /> SWEEPS I COMP 1 LOC CODE DIST CODEAMODUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> �.>M.y..' <br /> nw E i r.,rTq �etiAwi..'/IY&ijAd <br />