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UNDERGROUND SIu"^_�. <br />V <br />.Lily SITE II Vt�� <br />FACILITY ADDRESS � <br />L <br />I <br />T CITY C� <br />T <br />A APPLICANT/BIS G NAME <br />P <br />P <br />lNAS <br />I ILING ADOR <br />C <br />N CITY <br />7 <br />FACILITY CONTACI nM, <br />S---:: <br />LAREA CODE <br />TANKSITE <br />TACT WE <br />o --j <br />COO <br />APPLICANT PHONE E WITH AREA <br />z 0 •_ <br />APPLICATION <br />E j E,wc�iNSTALLATION, etc. <br />SWE 1 ZIP <br />1987 1989 1990 <br />1986 1988 i <br />TOTAL <br />a =100.00 <br />A January 1, 1991) 1, 1991) <br />C riot to ter January <br />5170/TANK (af <br />T ANNUAL FACILITY FEE (P 1994 1995 1996 <br />1 (prior to 111991) January O 1991 1992 1993 S <br />V 550.00 /TANK 1988 1989 199 <br />E TANK FEE = 1986 1987 <br />y tanks = -fee for Coda, Section 25287 <br />F (nultiplY by <br />1 A applicable) ears) See California N 4 <br />C each year apP (Dus every 5 Y 1991 through 1996s <br />/ 1 SURCNARGE s 556.00 each TANK 1990 <br />L STATE 1986 through <br />I Tanks_ x s56.00 <br />T (enter wwoLnt and year) <br />T TANK I.D• N(s) c <br />�y lace) K s159.00 <br />vat or Authorized Closure <br />I' -place) M <br />TANK(s) <br />HENT Cl.SURE (Remo ours r TANK) <br />PERKA (3 h mInimLA Ix <br />OFFICE USE ONLY <br />go 0,' ^•-- <br />EN 23 032 (REV 1/10/911 It <br />+ <br />