Laserfiche WebLink
BAN JUAOUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANk PROGRAM - FEE IIORKSHEET <br /> Illi!l111E RAMS JAN KOZAR FACILITY CONTACT NAME JAN KOZAR <br /> F AIMtEBS 14890 N. Alpine, Lodi , CA 95240 SITE PHONE 1 (with Area Code) (209) 368-6450 <br /> Y CITY Lodi , . SLATE I195240 atoSite <br /> NK�S N1 <br /> A <br /> P APPLICANI/IILLINB NAME Jan Kozar APPLICANT CONTACT NAME JAN KOZAR <br /> P <br /> L <br /> I MAILING ADDRESS P.O. Box 385, APPLICANT PHONE 1 (with Area Code) <br /> C (209)368-6450 <br /> A <br /> N CITY S E IIP aD TYPE of APPLICATION <br /> I Lodi 95240 (Closure, Installation, etc.) <br /> FACILITY FEE • 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1908 1989 <br /> T <br /> 1 1 <br /> V <br /> E TANK FEE ■ 150.00 each TANK <br /> F 1 Tanks 1 150.00 1986 1987 1988 1981 <br /> A (eultipli'I-by lee for <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE ■ 156.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T 1 Tanks s 156.001986 1987 1988 1989 <br /> Y (enter IWA and year) <br /> f <br /> C PERMANENT CLOSURE (Resowal or Closurq-in-place) <br /> —' r■flL 1 Tints 1_ s 190.00 f 90.00 <br /> RICH-MART --_—_—_ --- <br /> JIM THOgPE, DISTRIBUTOR OP QUALITY PRODUCTS -- -------- - <br /> 388-8175 452-4581 10874351 NO, BECKMAN ROAD, p,0, BOX 357 <br /> LODI, CA 85241-0' <br /> S Torg TOTHE <br /> PAY 357 <br /> a oiecouwr ORDER OF <br /> '.NONNY O[Cw[Ck '7 <br /> leo <br /> e - �O _ _ $ QjO O B <br /> ioo,o,ric2 ---- --------DOLLARS <br /> law Wfk R.,fedi.G fsxq - <br /> 11■010871,11■ 1: L2 & &0 &0371[ <br /> - - _ <br /> - -- <br /> 23111 <br /> FEE ■ 130.00/hr l --- ---- _ - - <br /> OFFICE ISE Hit <br /> IKIM I COR 11 LOC CODE IIST CODE I AMOUNT DUE I AMOUNT RCVD I CHECK I/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> �tt� <br />