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I <br />SAN ,dW UIN COUNTY ENVIRONMENTAL HEALTHRTMENT <br />UNDERGRC�JD STORAGE TANK PROGRAM F c WORKSHEET <br />APPLICANT BILLING NAMF <br />CONTACT NAME <br />1999 <br />snolxlw:,rs) <br />CARRIE MILLER <br />FA ILITY ADDRES <br />?A0�- <br />SITE PPHHON/E'#) W TTH AREA CODE <br />B <br />lJ/ (IYJ�J'I <br />CffY STATE <br />ZIP CODE # OF TANKS AT SITE <br />CA <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />APPLICANT BILLING NAMF <br />AC IIVE FACILITY <br />ggr.nrEEtNCL,UDESFACIF!T1'FEC-+-1'TANK- <br />a UN1A61 NAMEELITINC. <br />1999 <br />snolxlw:,rs) <br />CARRIE MILLER <br />APPLICANT <br />?A0�- <br />APPLICANT PHONE # WITH AREA CODE <br />tC�ONTRACTO;RS, <br />2535 <br />CITY <br />(209) 461-6337 <br />ZIP CODE CIRCLE WORK TO BE DONE: <br />STOCK <br />95205 <br />Closure Installation Repair Retrofit <br />AC IIVE FACILITY <br />ggr.nrEEtNCL,UDESFACIF!T1'FEC-+-1'TANK- <br />1998 <br />(rid.;,(#wrt —7.. <br />1999 <br />snolxlw:,rs) <br />2000;-,2001_,_2(202 <br />?A0�- <br />- <br />1125 PER TANK AFTER FIRST TANK <br />t <br />a <br />a <br />iTANK PENALTY ASSESSED - <br />$ <br />TANK SURCHARGE = E1.0/T <br />ANK _ <br />$ <br />STATE SURCHARGE FOR FACILITIES NOT ALREADY ON INVENTORY IN A CUPA PROGRAM =$17.50/ FACILITY <br />$ <br />I PERMANENT CLOSURE <br />' rival or Permitted Closure in Place <br />TANK <br />TEMPORARY CLOSURE FEE $279 / TANK # TANKS <br />CLOSURE <br />(Plan Review and Inspections) - <br />TANK ID # (s) : TEMPORARY CLOSURE FEE = $2791 FACILII <br />MISCELLANEOUS _ <br />RANcFEP. FEE _ $?O <br />CONSULTATION FFF = -CC <br />W FEE <br />■ <br />FFICE USE ONLY <br />:RVICE REQUEST # FACILIry 1D AMOUNT RECEIVED I CHECK# RECEIVEDBY DATE <br />123 032 (REVISED #/01103) <br />