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SAN ,J*OU I N LOCAL HEALTH D 18'O CT <br /> 1NDER9ROIZtiD STOApBE TAX PROQRAI4 - FEE HDRI(WT <br /> /F FACILITY/SITE NAME FACILITY Ca1TACT NAlfE <br /> A Pony Express Courrier <br /> C 4. <br /> L STREET ADDRESS 959 Moffat Blvd. SITE PHONE I $with Area Code) <br /> i 209 823-4512 <br /> T <br /> Y CITY Manteca STATE IIP CODE 1 0l TANK'S <br /> • CA at Site l <br /> A APPLICANT/BILLINS NAME APPLICANT CONTACT NAME <br /> P Pony Express Courrier <br /> P Gloria Davi <br /> 1 MAILING ADDRESS 263 S. Maple St. APPLICANT PHONE i (with Area Code) <br /> C (4T5)952-3300 <br /> N CCTV STATE ZIP CODE TYPE of APPLICATION Tank Removal <br /> T So. San Francisco, CA 194080 (Closure, Installation, etc.) <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A <br /> C 1986 1987 Ina 1989 <br /> t f <br /> V <br /> E TANK FEE _ 150.04 each TANK <br /> F 1 Tanks 1 150.04 1986 1967 1989 1939 <br /> A (auEltipTy-I-by fee for <br /> C each year appli(able) t <br /> I <br /> L STATE SURCHARGE _ $56.40 each TANK (see CA HEALTH t SAFETY CODE Sec 25207 for applicability} <br /> I <br /> T I Tanks_____ r 156.00 193b l98] 1998 1989 <br /> Y (enter aeount and rear) <br /> S <br /> C PERMANENT CLOSURE (Reeoval or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE a 190.00 each TANK I Tanks 1___ r !94.40 k 90.00 <br /> iL <br /> THM CHKCK Yi OELKIFKEo FOX fL—C.T <br /> DN THE foL6 -.N6 NC.PUNTL <br /> RICH -MART 10441 <br /> JIM THORPE. DISTRIBUTOR OF QUALITY PRODUCTS <br /> 368-6775 462-4581 <br /> 351 NO, BECKMAN ROAD, P.O. BOX 357 — rte, 80-103/1211 <br /> LODI, CA 95241-0357 <br /> RAY �^ ,y7 01 r1 <br /> � TOTAL ORDER y1 <br /> PINCoUNT <br /> DOLLARS <br /> Y AMOUNT OF CHECK <br /> . <br /> lOF)1 OtFlCE <br /> 120 W.Walnut St.,Lok CA 95240 <br /> I11IAL IM 1 1 <br /> 20-- - <br /> oFFtCF USE ON(Y <br /> SWEEPS I COMM' I LOC CW )IST CODE MINT DUE MOUNT KYJ CHEGk NCA60M RCV4 ly BATE RECEIVED PWIT I <br />