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11/b4/21Jb4 16'3: J2 1b'J4b8J4JJ rlrirl rLUUK <br />SAN JOAwft COUNTY ENVIRONMENTAL HEALTH DEP TMENIT <br />UNDERGROUWSTORAGE TANK PROGRAM FE IORKSHEET <br />o� mvkNlo <br />MLITY ADDRESS <br />STA <br />CA <br />"LICANT MAILING ADDRESS <br />Cc 1 q I 'S i C` iZ� �, 66 <br />;RY I STATE <br />`N)6 \- 11`-e 1 (A <br />rWat ri7 <br />1BP-11Q 1 CZ \11hz M I A <br />SITE PHONE # WITH AREA CODE <br />:�Be6--(-Dz:)I <br />ZIP CODE # OF TANKS AT SITE <br />q5�3s& Z, <br />APPLICANT PHONE w WITH AREA CODE <br />CIRCLE WORK TO BE <br />�- (9 I Closure Installation Repai <br />1999 2000 <br />$SOO FEE INCLUDES FACILITY FEE+ 1 TANK (&170)x("nkal <br />$125 PER TANK AFTER FIRST TANK <br />TANK $UKUMAKUt_ 0;1101 14 <br />STATE SURCHARGE FOR FA <br />PERMANENT CLOSURE <br />(RPmovai or Permitted Closure <br />TANK ID # (s): <br />TEMPORARY, <br />(Plan Review 2 <br />TANK ID # (s) <br />NOT ALREADY ON INVENTORY IN A <br />a $279 / <br />2002 <br />FEE = <br /># TANKS X $279 = <br />Retrofit <br />✓v � L <br />