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/ SAN JOAQUIN LOCAL HEALTH DISTRICT �\ <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> Iu11rT/BIit NAME FACILITY CONTACT NAME <br /> SM CREEK WINERY RUBEN NF.GRFTE <br /> sitar ABDRESS --- SITE PHONE i WITH AREA CORE _- <br /> 11900 NORTH FURRY ROAD <br /> Y CITY STATE iIP CODE 1 of Tanks <br /> §` LODI -- . —---- — ------_���_J.-2524-_.._ at S1 t e _. -- —-- — <br /> P APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> R.M.F.J_ENPERPRISES—_—__—___..._........._____—._ —_......_...F4LST JA�KSOi9---- <br /> 1 MAILING ADDRESS APPLICANT PHONE 1 WITH AREA C00E <br /> A 6637 BRI TREE WAY 21 [21_-.1.4`x._-.—^__ <br /> T CITY ISTATE ilP CODE TYPE al APPLICATION <br /> /�AHT�SQ CLOmwRl. /NETALLAT ION" [TG.CITRUS rT� <br /> SStila+_- .a.a�. <br /> FACILITY FEE = $100,00 each SITE ADDRESS per YEAR TOTAL <br /> A _ —.—_-- ----I - - — . 1. —..- -- <br /> _1987 --_19881989--�-----_._ s—�.� <br /> V L <br /> E TANK FEE _ $50.00 each TAITK <br /> F 1 Tanks _ x $50.00 1986 1987 1908 1989 <br /> A (multipry_f_by ---- <br /> C each year applicable) - <br /> I PAYM _H r f <br /> -- — -- - - <br /> L STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH L SAFETY COU q'l Oapplicability) <br /> I 1 Tanks_____ t 156.00 1986 1987 �C(�88; �1 1989 <br /> Y (enter amount and year) --- - -- - — - - — — <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) 1S€RVICES <br /> L -- <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanks 3 x $30.00 $ 270.00 <br /> S- <br /> U -----_... -----�_-_ <br /> U ...-- —-- ---- ------ — _.—�— — <br /> _— P TEMPORARY CLOSURE (Only allowed one time for up to two years) <br /> tan an_ 1 <br /> ROBERT McCULLOUGH 7-69 125 —. <br /> FORREST G. JACKSON <br /> 5637 BRIARTREE WAY 721-1492 -'-------- - <br /> CITRUS HEIGHTS, CA 95621 �D�© <br /> 19-QLQ_ 910-7111011/25 <br /> TO 3211 <br /> OHRYDER OFEVik Im#5-A ..---_ S-- <br /> -- —. <br /> --- <br /> fT I $ �70 q7 <br /> • DOLLARS _.._..... .S_.._..._.__ __ <br /> Sacramento Savings I - <br /> ANTELOPE OFFICE <br /> 7695 Lichen Drive /Citrus Heights,CA 95621 <br /> M.... . �- 1 270.00 _ <br /> OFFICE USE ONLY <br /> DIImPI ! » P C PDP ; ; M').;P P,II!m'.4 '19i;.9" "I, 11Nmf IT I'I:T11'. fp,l. »ul(:'P'iir'Ir.N!il'� NiP:I!iII!I P ^,'!���!P�����II�IIPI!LP�"IPI"�'yP bf IV�I�I�!9MPMPP�PPPa 9P49.JI..I�IPVP i V�'PIP)'P�Iui1111P J.PiI,M��,N91V!�"aP 1I��PJP�uI�G P11 �6u119G ISN�11w!�'16,I..uNI IVIV121�W WPl l u6, I„9. � �r 0 IPS �u9�1 <br /> �yI SWEEPS 1 COMP 1 LOe CODE DIST CODE AMOUNT DUE AMOUNT RfVD CHEiI !/CASH.I RrVO DY �DDATE P,ECEI 'ED PEPMIT I P'' <br /> PJ . RITiII7"G�dJll ^rl II XPi a X91��"1�— <br /> ^1 D Co <br /> I.PI�PN )Ell. rin ,!gSIX '?piI�NLP.:1!2PP��IIP1PPl,:�l I�I:x,l gI�IPMIAlll.711 NIIIV(�JIP"I JI 11�1�!Pllu9�"DLII II I v 1 � A II ll'PO�:11 <br /> � <br /> l�r�� _ <br />