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SAN IN COUNTY PU/Lle S ALT lEAV10E5 • <br /> rpt MVIRONMEXTAL HEALTH DIVITIdN <br /> UNDERGRCUTTiID STORAGE TANK PSOG>llUl ' FEE UCRKSHEET <br /> FACILITY CONTACT NAME <br /> dr£NAME <br /> ITII P 1 0 With AREA CCD/ <br /> /A CIL l ry ADDRESS I, ;V =.• ` <br /> 1 <br /> CITY 7 m i STATI Itp Ccol 0C of SITAM <br /> y `ivux. .T>Jvn <br /> A APPLICANT/TILLING NAME APPLICANT CONTACT NMI <br /> Ap*LICJWT PHONE A WITH AREA CODE <br /> NAILING AD" SS <br /> D ?LI 1_�C O <br /> A STATE ZIP CCOC f APPLICATION <br /> N CITY p CLO" INSTALLATION, 4t0, <br /> TOTAL <br /> 1986 1987 1988 1949 1990 <br /> - $100-06 <br /> 4100 ,I <br /> T ANNUAL FAC0.ITT FEE (Pr1pr to January 1, 1991) .06 5 <br /> 1 <br /> E TANK FEE 550.00/TANK (prior to JenuarY 1,1991) 117d/TIMK ' (after January 1! 1991) <br /> � y Tatdta <br /> 1986 198( 1984 1949 1990 1 1 )992 1993 1994 199$ 1996 <br /> A (aultiply M JW fa for S <br /> C each year eppllcable) <br /> L STATE SURCRAROE • $56.00 each TANK (Due every 5 years) Sae Gl`}ornia X L 4 Code, Section 25287 <br /> 1 1986 through 1990 f 1941 through 1996 <br /> T a Tanks__ x 356.00 - <br /> Y (enter amount and year) a <br /> PERMANENT CLOSURE (RenlovU or Authorized Cl*sure•in-Pt ace) AN I'O. II$) <br /> CE 00 <br /> L CLOSURE FEE • 553.00 per hour (3 hours miniazza per TANK) TANK a) K 5)59.00 <br /> 0 <br /> e ANK OF STOCKTON 90-in <br /> GOMM•H...L aAV IH Ga TPU9T I Z I I <br /> aTucxTOH.DLIIOMNIw l� (� <br /> CPLIPONNI II CUNTRPCTOR LICSN96]U9198 5/. 2 O Q O FT <br /> 009-820 N.UWON eT.,BTOCKTON. CPLIP. 95Z�5 o V J <br /> P.O. BOIL 90B BTOCKTCN.CALIF. 95ZU1-0+ 8 <br /> PHONE Z"/66G 8133 <br /> 5 <br /> Nr cc) <br /> e d p DOLLARS <br /> DATE CHECK NO. =our caNTi <br /> �a <br /> EF OF CQw%Sna.LoL)tw \SII Li.-11=1�G , 'EYLC <br /> STOCKTON SERVICE STATION EQUIP.CO.,INC. 5 <br /> 1: 121 ;0103171: 2111125055 310 <br /> IN ;I <br /> 2$B051 S 1 <br /> , oO <br /> OFFICE USE ONLY _ •_ _w ,„•__.........__. <br /> „...„....„..__._.__.........y.�r.w i'::>.Ywwwrw$�:„•.iw.wwrr.a.Y• :ilr�l'wwiaBsJ�. nom.ir'3wiii3iw.Mr DA1 IlCLE 1�eY dial <br /> M n.a•6Y.w W I,f <br /> 31's�ec�`4' '• C TjFFi C ) '�slYamP (1�F'b _�)^ �.{�I•'1 <br /> a ...„..........„.... „................_.... . .... wrri,r�i Nirw'��7Y9�iw•Ia�I ITIiwas <br /> ,{ i. �iM..lyt�I11 (. .f4'•l a/ <br /> aMrwrw WwwwwW w�T_.. aa.l <br /> Yra� ^iiM M •• � <br /> ww.•ararsararl•rarararll•�ww+•Fawwrrrar�w ara•wr r,•rw,, ras I rr rww aw ra slaw�ia <br /> EN <br /> 23 032 (REV 1/10!91) ft <br /> I Peel, 1) • I <br />