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SANOUAOUIN LOCAL. HEALTH DRICT <br /> UI@E11RO1111 STORUSE TANK PHUM - FEE WOItlfWT <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> A Pony Express Courrier <br /> C <br /> l <br /> L STREET ADDRESS 959 Moffat Blvd. SITE PHONE 1 (with Area Code) <br /> I 2.09 823-4512 <br /> T <br /> Y CITY Manteca STATE LIP CODE 1 of TANKS <br /> CA at Site 1 <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P Pony Express Courrier Gloria Davis <br /> L <br /> I MA1llN6 ADDRESS 263 S. Maple St. APPLICANT PHONE 1 (with Area Code) <br /> C415 952-3300 <br /> N CITY STATE 11P CODE TYPE of APPLICATION Tank Removal <br /> T So. San Francisco, CA 94080 (Closure, Installation, etc,) <br /> A FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1988 <br /> T. 1986 1987 1989 <br /> I $ <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F 1 Tanks $50.00 1986 1987 1988 1989 <br /> (#IA leby lee lar <br /> C each year appli(able) f <br /> 1 <br /> L <br /> STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks r $56.00 1986 1987 1988 1989 <br /> Y (eater iiouit and year) <br /> f <br /> C PERMANENT CLOSURE (Resoeal or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE - 190.00 each TANK1 Tanks_]... $90.00 f 90.00 <br /> 5 <br /> RICH - MART 10441 <br /> JIM THORPE. DISTRIBUTOR OF QUALITY PRODUCTS <br /> 368-6175 462-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 90-103/1211 <br /> LODI, CA 95241-9357 <br /> 19PAY — <br /> V'E <br /> ORD C / / <br /> MAM.UN <br /> TOT HE ("J._// $ <br /> ORDER <br /> DOLLARS <br /> LODI OFFICE — <br /> IM W.W,ITUI 51.,Lodl,CA 95210 <br /> IYIAL INE If s) ' <br /> OFFICE tlSE ONLY <br /> SWEEPS 1 COMP i LOC COTS 1181 CODE AMOINIT DUE AMOUNT RCV@ CHECK 1/CASN RCVp lr DATE RECEIVEI PERMIT 1 <br /> 16�o Pvvyc'�s <br /> 32--61 9D 119gVi <br />