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Awul W LUCAL HEALTH D *-h' I Cl- <br /> DERGROUND STORAGE TANK PROGRAM - FEE WDRKSHEET <br /> FACILITY CONIACT NAME <br /> F FACILITYISITE NAME <br /> I SITE PHONE 1 11118 ANCA CODE <br /> L STREET ADDRESS <br /> 1 ✓�+� <br /> T A IIP CODE I of Tanks <br /> Y.C1IY r1 ��, ����(� at Site <br /> A APPLTCANTlBILLING NAME <br /> APPLICANT CONTACT NAME <br /> P Y'Y' ( L <br /> L APPLICANT PHONE 11TH AREA CODE <br /> C MAILING ADORES L4?IS; m aAti1 0 S ct, ;Lo9 Yg- -- 07 <br /> NCITY STAT IIP CODE TYPE of AP <br /> I � �' L CLDtlURE� @TALLATIDN� 1C. <br /> -� TOTAL <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR _ <br /> A 1986 1987 1988 1989 <br /> C _ <br /> T IOQ � 1 nd <br /> V <br /> C TANK FEE 150.00 each TANK _ ---- <br /> F I Tanks ,�_ % $50.00 1986 1987 1968 1989 <br /> A (multiply by fee forJ� <br /> C each vear applicable) <br /> I <br /> L STATE SURCHARGE = 556.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> I <br /> T l Tanks x 156.00 1986 1987 1966 1589 <br /> Y (enter jaoUt and year) �-- <br /> I �— <br /> C PERMANENT CLOSURE (Reaaval or Closure-in-place) <br /> L1 Tants x $90.00 5 <br /> O CLOSURE FEE = 590.00 each TANK - - - <br /> 11-241259 t <br /> 12W IQ1 <br /> WELLSFARGOBANK G-f <br /> ®RE PETROLEUM 1120 KO,CAE T <br /> AhO0ESTGA.95354 005073 <br /> OX 67 BANTA,CALIFORNIA 95304 /� <br /> r / <br /> AMOUNT <br /> f <br /> c $ 1 <br /> f MOORE PETROLEUM <br /> 1 <br /> t <br /> I, <br /> SLEEPS I COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK IICASH RCVD BY DATE RECEIVED PERMIT I <br /> 05073 D <br /> I, Y I'I� IliI j��I °: �r i- in:1 i lid, :�N�li .. Ir�!I.PN III'IX11 I R 7 u,I::..P'I��IIEI�iI��C4i�I�����N.a�itO�A;I'Inlll,.,w�l'Y'u. �'h�ltl,I'I°`ii 1� I-�i,�!vl'plfulnn. rn i• <br />