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&GROUND STORAGE TANK PR06RAM - FEE MORKSHEEO <br /> F FACILITY/SITE NAME y .s✓✓j ;7?.V ,I �tic Z FACILITY CONTACT NAME <br /> A <br /> I <br /> L STREET AQDRESS / SITE PHONE I (with Area Code) <br /> T <br /> Y CITY STATE iIP3ODE # of TANK'S <br /> C f- j) I at Site �/0 <br /> A APPLICANT/BILLING NAME / i- -� r APPLICANT CONTACT NAME <br /> L <br /> I MAILING ADDRESS �7j, c'c' cc' 1/G APPLICANT PHONE # (with Area Code) <br /> C <br /> A - <br /> NSTATE IIP CODE TYPE of APPLICATION <br /> T t �y��.� y� (Closure, Installation, etc,) C/e;S <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 1988 1989 <br /> T <br /> I $ <br /> V <br /> E TANK FEE = $50,00 each TANK <br /> F I Tanks x $50,00 1996 1987 1988 198P MIZNT <br /> A (aultipTy--f-by fee for <br /> C each year applicable) $ <br /> T <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25287 for applicability <br /> 1 <br /> i I Tanks x $56.00 1986 1987 1988 QIV ENTAL <br /> Y (enter amount and year) U LRMI SERVICES $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-,place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK # Tanks_ _ x $90.00 <br /> S <br /> I <br /> DATE INVOICE AMOUNT 90-108 <br /> WESTERN METER SERVICE, INC, • I Q 1211 <br /> 2735 TEEPEE DR. SUITE E (� r� <br /> STOCKTON,CA 95205 9 4n} L <br /> (209)948-6124 <br /> PAY t ILARS <br /> DATE - TO THE ORDER OF GROSS AMOUNT DISCOUNT CHECK AMOUNT <br /> _ BOTHER ACCTS.PAYABLE <br /> 1 s. <br /> WE TERN MET SERVICE, INC. <br /> UNION SAFE DEPOSIT BANK v <br /> STOCKTON,CALIFORNIA <br /> 11'0094 5 211' <br /> vrriLC UJC UNLI <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHE /CASH RCVD BY DATE RECEIVED PERMIT II <br /> 10 <br /> Ili <br />