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* ; ERGROUND STORAGE TANK PROGRAM - <br /> F FACILITY/5I1£ NAME {EF 118RKSHEET <br /> A <br /> C FACILITY CONTACT }TAME <br /> L STREET ADDRESS <br />{ T SITE PNON£ I (with Area Code) <br /> Y CITY <br /> STATE 11? CODE 1 or TANK'S <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME r�r��fi _ ¢A <br /> I MAILING ADDRESS <br /> C <br /> A APPLICANT PHONE 1 (with Area Cyd`e <br /> CITY <br /> STATE IIP CODE • TYPE of APPLICATION <br /> A (Closure, Installation, etc.) <br /> FACILITY FEE _ (100,00 each SITE ADDRESS per YEAR <br /> C - TOTAL <br /> I907 1988 <br /> 1906 1989 <br /> V <br /> E TANK FEE = $50.00 each TANK 1 0 C-3 <br /> F I Tanks _ x $50.00 1986 <br /> A t.ultiPlY T-bY fee for 1987 1989 198') <br /> C each year applicable) <br /> I <br /> L STATE SURCHARGE = <br /> 1 156,00 each TANr (see CA HEALTH b SAFETY CODE Sec 25207 far a�abiIit ) 1 <br /> T I Tanks x $56.00 Y <br /> Y (enter aaoulit and year) 1986 1987 1989 <br /> 1983 <br /> C PERWENT <br /> 3 <br /> L <br /> 0 CLOSURE 1 <br /> S RAMCON <br /> U FIELD ACCOUNT <br /> R TEMPORARI PH. 916-372.7535 342 <br /> P.O. Box1024 <br /> f f <br /> TEMPQRARI wesr SACRAMENTO, CA 95691 <br /> PAY TO THE - 90-3631/121( <br /> ORAE OF <br /> P PLAN CNE( $ / <br /> A ! <br /> N PLAN CNE( C%PITOL � DOLLARS <br /> B,1NN Off'COMMERCE <br /> REPAIR S VA14 <br /> Q MEMO.- 011 <br /> E TANK REP <br /> P �. L2ia36329 <br /> 034 2 0 &L 5907 u•0 Z <br /> A <br /> I PIPING R_.. <br /> R <br /> UNAUTHORIZED RELEASE EVALUATION CONSTRUCTION <br /> (when applicable) ,. SAMPLING INSPECTION INSPECTION <br /> FEE = S30,OOlhr • <br /> FEE = $35.00/hr FEE z $35.00/hr <br /> S <br /> 0rrlrr USE ONly TOTAL DUE <br /> I COMP I LOC CODE DIST CODE <br /> AMOUNT DUE AMOUNT RCVD CH CK !CASH RCVD DY 6A TE RECEIVED .PERMIT I <br /> � q <br /> ry " + ` r1;. <br />