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I II._. 1-.• rvl ML_ rill l r1 , - i I KJ.L. t <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSNI:ET <br /> F FACILITY/SITE NAME <br /> A FACILITY CONTACT NAME <br /> L i �GtJE�TI — <br /> D�N <br /> L STREET ADDRESS <br /> I SITE PHONE 1 (with Area Code) <br /> T / 70 _e Ji — 5 <br /> .� Y CITY STATE ZIP CODE 1 of TANKIS <br /> at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> 1 MAILING ADDRESS <br /> A U 3 j/ APPLICANT PH NE 1 (with Area Code) <br /> H CITY X96 3 � — <br /> I STATE IIP CODE TYPE of APPLICATION <br /> (Closure, Installation, etc.) e/Q <br /> FACILITY FEE 1100 <br /> = .00 each SITE ADDRESS per YEAR <br /> A roraL <br /> 986 1987 1988 1989 <br /> ( <br /> V 1 <br /> E TANK FEE = $50.00 each TANK <br /> r F I Tanks 1 150,00 1986 <br /> A (oultlpfy-f-by fee for 1988 1999 <br /> C each year applicable) <br /> I f <br /> L STATE SURCHARGE = 556.00 each TANK. (see CA HEALTH L SAFETY CODE Sec 25207 for ability) <br /> T 1 Tanks : $56.00 1906 1907 <br /> Y (enter iiSGEt and year) 1900 1909 <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = 190,00 each TANK <br /> U - - — 1 Tanks__- It f9o.I f t� <br /> -- <br /> E — --- <br /> RAH ENVIRONMENTAL PAYMENT <br /> P.O. BOX 3311 916-348-7777 R E C E I V E p 695 <br /> P CITRUS HEIGHTS, CA 95611-3311 <br /> L11-21/151 <br /> A PAY T I( I - 1 J3 -�4 1210 <br /> M THE <br /> LGG"l.Q <br /> ZUOROF �, <br /> �E�vrc�s T � $ <br /> m <br /> R — / <br /> E GREENBACK- -DO A R S <br /> SAN JUAN OFFICE <br /> A WELLS F GO BANK <br /> ` I 1 BACK LA TRIS HEIGHT <br /> R FOR D.r, Wf'�. <br /> ss o <br /> I � D�GL <br /> .. � <br /> 112000695110 1; i 2 1000 2481;0 154 269 7110 <br /> OfFlCF USf ORIy TOTAL DILE f <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD HECK ASH RCVD BY DATE RECElVEO PERMIT <br />