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10 <br /> SA DUIN COUNTY PUBLIC HEALTH SERVICES , Ye <br /> "`UUU ENVIRONMENTAL HEALTH DIVISION <br /> A000 UNDERGROUND STORAGE TANK PROGRAM FEE UORKSHEE( <br /> rp <br /> FACILITY SITE NAME FACILITY CONTACT NAME <br /> f <br /> A Robert Lord Bill Lord <br /> C <br /> I FACILITY ADDRESS SITE PHONE M with AREA CODE <br /> L 428 W. Pine St. (209) 478-4515 <br /> 1 <br /> 1 CITY STATE 21P CODE / of TANKS <br /> r Stockton, Ca. 95204 at SIIE 1 <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Robert M. Lord Bill Lord <br /> P <br /> L <br /> I NAILING ADDRESS APPLICANT PHONE / WITH AREA CODE <br /> C 434 W. Pine St. (209) 478.4515 <br /> A <br /> N LIIY <br /> STATE ZIP CODE TYPE of APPLICATION <br /> 1 stocktort, Ca. 95204 CLOSURE, INSTALLATION, etc. Removal <br /> TOTAL <br /> A <br /> C 1986 1981 1908 1989 1990 <br /> I ANNUAL FACILITY FEE (Prior to January 1, 1991) $100.00 gg <br /> I X X X X X S X 700.OU 'T`• <br /> V . <br /> E TANK FEE 550.00/TANK (prior to January 1,1991) 5170/TANK (after January 1, 1991) <br /> r 1 Tanks _L 1986 1 1981 1 1968 1989 1 1990 1991 1 1992 1997 1 1994 1995 1996 <br /> A (mdtlply 5 by fee for - - — -- - — S r� I <br /> c each year eppllcnble) X X X X X X //00.00 <br /> I <br /> l STATE S(MCNARGE • 556.00 each TANK (Due every 5 years) See California N 9 S Code, Section 25287 <br /> 1 <br /> 1 N Ienks a 556.00 1906 through 1990 1991 through 1996 "q <br /> Y (enter eawult and year) <br /> X X a 112.01 <br /> tdl <br /> PERMANENT CLOSURE (Removal or Authorized Closure-inPtace) TANK I.D. N(a) <br /> C - <br /> L CLOSURE FEE • $53.00 per hour (3 hours minloan per TANK) R TANK(a)--i_ X $159.00 5 159 QU <br /> 0 <br /> ON T..row` ACCOUNTS <br /> — JIM THORPE OIL, INC. 3322 <br /> _ DISTRIBUTOR Of QUALITY PRODUCTS <br /> 351 NO. BECKMAN RD. 368-6115 462-4581 ' <br /> P.O. BOX 357 <br /> LO D1, CA 95241 19 n 90-8441211 <br /> PAY <br /> - - <br /> TOTAL TOTHE �F. <br /> Y ORDER C�C.... <br /> O,IGO VNT <br /> AMOUNT e Q °DOLLARS <br /> FARMERS & <br /> MERCHANTS <br /> '111 BANK NOW* � <br /> Q <br /> TOTAL DUE <br /> OFFICE USE ONLY <br /> ...................._........................................................................................................ ..........» ................ .... ... ..................................................... ,. <br /> w....r+rw•w•wxwaaawa�.a..a•YAwalw.:n,.awlfl�W,iw.NN•pM tMm twawr.wx�.Mw MaMMw wr•aMa�wwa•.r�ar1MNi X►is,�wasMa••iW�Awr MMl�wa�xMwwi•Yw'�I•i�,awawe i�Ma/itwywl A•Wr/w�Na Nw�xwl awW/•trw�MP xr•wwrswlwl swlalWw MA <br /> M:Yaa/a1l•Y'MY lAT'UItM IrMf lUl UIS'1 L�lt NI�1XI RL'N `rTT''�lHtlR 11/��15{I �Xk Lt1 Vt1) tl1 � 111111 NtC1:lYc1/ i <br /> SV�F�� ■.... ............ .... ..... ...... ..................�......11_ __— <br /> 0 33 <br />;N,..N.«.N.:•••,:•:•••».•«.••«N•«.«::wY•.:b..••.•»,..,.....w..NN•N•••N...•..N•» <br /> M SNMMaMMMMMMa1MMeMMW MMIMMMFYaMMMMMaMMMMMAMMMAYMMM MM McMMMYMMMMMMM MMM MMM(MMMMMMeMM <br /> r Paa <br />