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. . ' ..r.'�•,_•• •..L,..nL Mt_nL1H D :l-RiCI' <br /> _ HDERGROUHD STORAGE TANK PROGRAM - FEE WORKSNEfT <br /> A FACILITY/SIiE NAME <br /> C FACILITY CONTACT NAME <br /> L STREET ADDRESS <br /> T <br /> C C SITE PHONE 1 WITH NASA Cool <br /> Y CITY <br /> ST I 11P CODE 1 of Tanks <br /> A APPLICANT/BILLINGNAME at Site <br /> P <br /> P APPLICANT CONTACT NAME <br /> L <br /> I MAILING ADDRESS <br /> C <br /> A APPLICANT PHONE I WIIK •cc• coot <br /> 1 CITY <br /> STAT 11P CODE TYPE of APPLICATION <br /> I04TALLw1IoW, Nye. <br /> A FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> T 1986 19871988 TOTAL <br /> 1989 <br /> V <br /> E TANK FEE = 150.00 each TANK ( I- �I <br /> Il '�_, f 1 <br /> F I ranks I _ r 150.00 <br /> A (eullipry by fee for 1986 1987 1988 1989 <br /> 1 each year applicable) <br /> L STATE SURCHARGE = 156 <br /> I .00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) 1 ,` <br /> T 1 Tanks s (56.00 <br /> Y (enter a5ht and year) 1986 19871988 1909 <br /> 1 r. <br /> C PERMANENT CLOSURE (Res <br /> oral or Closort in place) <br /> 0 CLOSURE FEE = 190,00 each TANK <br /> S ---_ 1 Tanks Y <br /> --- ------ Fal 1— ---� 190.00 <br /> WELDON, WELDON d COWELL CONTRACTING <br /> 69 <br /> ROWAN.'J. <br /> ORNIA 95323 <br /> (209) 874.3722 r -- — 2089 <br /> fAX (209) 874-3723 I--_--_ _ <br /> CENTRAL BANK <br /> WATERFORD CA 95386 <br /> PAY THg 'U <br /> TO THE L*' <br /> ORO <br /> DATE„ CHECK NO. <br /> ER OF a. �/L._ / O AMOUNT • <br /> I <br /> OVER $500.00 2 SIGNATURES REQUIR O <br /> AUTHO RIZF]GIG NATURE -- <br /> OFFICE USF ONLY TOTAL DUE <br /> S�EPSI' ,. C�1 OC CODE DIST COBE <br /> R Nr V CHECK 1/CASH ACVO BY DATE RECEIVED <br /> ,I A <br /> I I <br />