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+ SAN—IOAQUIN LOCAL HEALTH DTSrTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> C The Service Station Sharon or Clyde Walther <br /> L STREET ADDRESS SITE PHONE 1 WITH AREA CUam <br /> 1 -1100 West Eleventh Street _ 209-836-5203 <br /> Y CITY STATE ZIP CODE 1 of Tanks <br /> _Tracy, STATE <br /> 9537_6 - at Site _- 1 (One) --- _ <br /> A APPLICANT/BILLIN6 NAME - APPLICANT CONTACT NAME <br /> P Carl D. Navarra (Owner) for <br /> P The Service Station Clyde Walther <br /> L -- -------..__.—...__ -- ----- <br /> I MAILING ADDRESS APPLICANT PHONE 1 MIT" AREA CODE <br /> A- lino Wpct Eley ntl�Rtrgt_ <br /> e ----- <br /> 209-386-5203 <br /> N CITY STATE iIP CODE TYPE of APPLICATION <br /> T Trac CA. 95376 CLosuee, I"eTALLATIaN, ETC. <br /> . Yc - - _,-- Closure <br /> FACILITY FEE = i100.00 each SITE ADDRESS per YEAR -- TOTAL <br /> A .._.._-- .._._.__..----.._ X R .. . - - - -- ----- <br /> V -- 198 - — 1981_ 988 `- -196 <br /> $400.00 <br /> E TANK FEE _ $50.00 each TANK <br /> F i Tanks 1 x 550,00 1986 1987 1988 1989 <br /> A (multiply-t-by fee for ---- --- - <br /> C each year applicable) X x x x - $200.00 <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability) <br /> I - -- -- - <br /> T 1 Tanks k_ x $56.00 1986 1987 1988 1989 <br /> Y (enter iiount and year) --- - <br /> ---- - _-... --- -- X 56.00 <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) — - <br /> L -' ----- -.-_._--_.....-. -- <br /> 0 CLOSURE FEE _ $90,00 each TANK 1 Tanks_y--_ x $90.00 $ 90.00 <br /> U <br /> P, l <br /> E THE SERVICE STATION 5242 <br /> 1100 W. 11TH ST. 209-636-5203 <br /> TRACY, CA 95376 <br /> P F ` ( � 7s G� 1211A / 0 <br /> fl f TOTHE <br /> -- ? ORDER OF $ ;'7 i l ad <br /> DOLLARS <br /> R <br /> E-" ai <br /> r ur Nara a/aiN 3hwt <br /> P MNNbaq CaIUo.N a casae <br /> AF <br /> ( FOR -[.vz. <br /> Rl <br /> 1 1 <br /> F <br /> TOTAL DUE $746.00 <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RF,VD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT t <br /> INAMB mm.Rpp..�.7./... . .........L .. 16 9 .� Im <br />