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SAN JOAQUIN LOCAL HEALTH :l3zS'TR1CT <br /> • UN<�1: ROUND STOPAGE TARP, PROGRAMFEE_YORKSNEI:i <br /> _.. _ _._.-- - FACILITY CONTACT — <br /> (Fj FACILITY/SITE^NAME <br /> . ... <br /> 1CIIA71''i�li0� SF�FiLA— <br /> I�__ ...—......— —._._.,—,_—�- ••._.__.--- �1 1 E,PHONE 42 T>t AASA "rig <br /> I STREET ADDRESS <br /> _ S. ZIP <br /> �q31 36�� <br /> YCITY �_ _- _ _...__— _. STATE It? CGDEof Tanks <br /> S t�C.K. O►J __...._...�__ 9S7Zs a: Site <br /> A APPLICANTIBILLING NAME 4 APPLICANT CONTACT }FAME <br /> c-L c <br /> L ..--.._ _......._._. <br /> I NIt,ILtNS AGDRES APPLICANT F' ONE s uz~•k AREA c°°E <br /> !�� ..---•. ��4�_-��0-3�..��..M..��..� ► <br /> STATE IIF CODE TYPE of APPL1 1 <br /> A CITY YGI� sgs oLvaurer, A Err„ t <br /> FAC1l[TY FE£ = iI00.00 TOTAL <br /> each SITE AODRFSS per Yr AR <br /> 1_—..1997 198a_ _i9$9. 19 9U <br /> E TAN); rEE : i<,0,00 each rapt _ <br /> F ' Tank5 `�... .. ..i'36n.. .{. --1587 y 1988 I�gy 19c� <br /> IA (Aultipry Vby fee for <br /> t, ea(h year apy�licable) - <br /> LIVATE SURCHARGE _- 156�00 etch !ANY-(see- CA HEALT8 t SAWY CODE Sec25297 for afrolitabliity)�NT -- <br /> ri{_TaaK5_2, x s; ,.:0 r^ 19aG T (9BT -! 19x8 tai .... 1906 — <br /> Y�(enter a*oust and year) <br /> CTP£Rf1ANE}{T CLOSURE (Reaaval er...Closure-.sn-place) .._...__---- --....._,.__...�__ �.,•--'--....�.....-__..�.__...��_-.�..--W'-_.__--� <br /> 0 CLOSURE FEE _ 00.00 ea(h TANK_.. <br /> R TEMPORARY.CLOSUFE (Clnly allowed owtiye for uD to kuo years) <br /> E,^TE►1r^ORAPY -CLOSURE FEE - VW.00 reach TANIK <br /> fF�FIAI{ CIIECK...(tnskallatioo arr?¢pair) _......_�_ ......._�_-____._ ---.-- --.___.,. _ - - ...�•-.--�... I <br /> aE` T <br /> PLAN. <br /> ....... CHECK <br /> x r, �r.}: SUit°fIs'tf)4lr f:55RcEcelvep CI_K FES ._--'0,0 _.r "_a Earl:— - _..__, _.-- -• - - ....__ _ ..r_ ._�-- <br /> PEPAIR <br /> p } _ s G.00 each TANK �1VfRONMENrA # a.ls x 4.I t+).u0 --- — I-._ .._. - .._. _.._I <br /> -- <br /> !AN),' ..EFAII; fE.. lI L-y�, LT14---.. __._ .___ _ 1 <br /> I;I�F[PINO PEP1IRICLCISURE/RE)SOF:AL (fees are Ger hevr, alniflun Jr,Q hour to i�e.paid cc plr: submittal)' <br /> i u!!q(}TNORIIEO QelEr`.5E fVA�UP.T(1!{ ICONS! .jr INS'rCf[L}1 jSAmr'L{}SG IiNSFECTI1! <br /> ` I.vhen appllcablel ( hen aNpiicabie) Ili ��en app)icablE) - - <br /> ! ( { _.--1 0, FEE = $35,ri0/h .._._..._.....--. FrC 535,00t,tf —___--- <br /> FIE � <br /> `' TOTAL DUE s ov <br /> ofFrci: use ONLY <br /> •� r�• <br /> r.. '"�? �" `' 4+I�tF4"M�diA +t1{S n°.�iU! CEO!, -I�!�+t�tllil���r'TU�i��:�G?'i <br /> IMP.. '` � k�?�1����'i.F Nfid9 Ft. e•K d 'a M <br /> 23 15 1�1 <br /> 00UNT R;VD C}!ECK IICASH R,VD DY DATE RECENED ERMIT I <br /> St�EEPS ;i COKP t LDC CODEI DIST COLE A`!DUNIT GUt -- _ <br /> _............ .._..._.__...__ ....._._.�. <br /> 01 <br /> v <br /> Mr..t!"r`3 f.�::.�;tl fM'.;M! P.: 'r•i 1P!S' l"1�.E1"+I�r r?!'�m ti 7l^ .. '. ��na �i� litr �lWRI,5-11 ROOM <br /> rf,Ntl!K nhrc+l4�t i "�I�+h:k pftAti+I r+li „r. <br /> :ri!m.dl75pl�It li!G1�iln,hrhiy(�+)1+�fi�+�2.:y �1„ ny:'Ii:.R- -y+4. ..:.,4.1.di.511: L.r.!uF..::.Lly°;:{' .{ <br />