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SA�( : .xQl�E»UiN L_0C,AL .. HEA LTH :DI5'TR1Cr:..
<br /> UHOEMOUHD STORAGE-. ARY PROGRAM. FEE IfORKSHtEi Y_ ^�
<br /> rF FACILITY/51TE NAl1t~ -- - - :.' - .� -�---•-•----- -' I"ACILIYY:•L'L�NTACT•1IAtiE -''`
<br /> c S I-E�i� S IGE S�� -I a► _._ .__ 1-� PI,D . kr✓rN t21cIC
<br /> L STREET AtiDREc $ITE PRONE -# utta AAVA oars
<br /> 1 _ 131 ..�.l.�lG Avg ^1�.•_ C2.5f))-9sZ- &s8 1
<br /> 1 CITY r _ _ - r _ STATE
<br /> ---I TY C6It"I Tanks
<br /> I at site
<br /> Al APPtICAHTI6l:L11I0 HAtIE J- r -�-•__ -- y~T~T_ APPLICANT CONTACT NAK
<br /> P ��Br� ._. ._ �' ta�`�GtA cS ��� �.AUI,E`( {
<br /> -• � U2Tk naris,, cavi
<br />- I nntl.t,�s �DD�E�s ,•PPuc>�TIT PHONE �
<br /> N ':TTY LZlF''C ecYcsvaz lR%.TA«ATr . arc• —
<br /> • _�.._.-.: ....�..�_.----•;--=f----:y._.__._.._.M: _.• .---- ..__._---- -- ._.... ---__.._^._.�� __. ....-TOTAL V I
<br /> -I FACILITY f�£ 1100,44 mh Sl i.. ADDRESS;per FEAR-
<br /> Ai..
<br /> yI937
<br /> I �......-_ fav ��� Ic�c�.""—_•�_
<br /> �E TANK I FEE i50.00 each TAN I. •'S- • _
<br /> Tanks � E8!9 l°$y C)�
<br /> F s _;3 x :50<00~ i'IV6. 1387 f
<br /> I A (>zu l t i p)y -by fee for
<br /> 1, each year
<br /> rSURCHARGE - 156.00 each, TANK ( e, CA HEALTH t. SAFETY LODE Sec 25287-for aG9licabtli;yl�
<br /> L S1k.E �- s _ _ ___•. __.__ .......-....._._ -----I
<br /> Ij^} Tanks y3 ^x i,6;`t066 T........1987 _._. .088 �~l;8's ....
<br /> (enter mount and year) ..._. �(- _--- _....__._....,..__.__._•- �j ._1 ..�Ila8 or^_.
<br /> I:iPE'RIiANEtII CL05UkE- •:Reaoval er Cl'.surc-in-riacE) _..._. ._._.._..-•---....._.____.._._�_---.�.----�T__..._-. __T__
<br /> 41CLOSURE FEE - X90,00 A40 IAN'r.
<br /> F TEMPORA£Y.CLOSUFE-(Only-alloaeo,�e__ti:le -f -, 'VD to tv0 years) --
<br /> E TEAPORAP•Y CLOSURE FErE, ; fiSu.UO facts TANK T IankS x 380.09wM__
<br /> IP�PLAIN CHSCK�(Insl lahon or_R0air) _ y~ _
<br /> ( p0
<br /> IA
<br /> 'rl PL& CHECK FEE - .aU.CG zaci: 5'Jis(ISSiti,l�FESi'ihiSSfOI( _ .. _ .r__`.._.-- - 1.= 3G. _ -�_.►
<br /> I pi TAN?_ REPAIR FE'..- ~.110.40 earl^ TAHI:.._- --..__.... _...._... ..#-lams_---.., x .!IU,u'+ ......_._ �.>_n-s-r^ t-o.....- ------•--•�-- 'abe paid orplirsubmiktl l
<br /> PIPIHG REPA'R^ICLOSurEREIO`AI (F. are p•vhos ainSflVA or,e
<br /> �,;VaUTNUFI2;4 D'etEASf EVA;UrtT(OiI �C4l;ST"nU+.:iOlt {N;r�ECTICI! SAMPLING INSPECII II
<br /> „ able? � When applicable)
<br /> -When appltczblel (vhen 4ppH c
<br /> I ._. _.._. •
<br /> IEE >> --- -._•._.-•----- -..FEE -C._Ur,lhY( ..__ __......._---••- •Fi:l: _ .S'sS.U0/ht -. �_.._------- ; _._. _ --
<br /> { --...S30:Gt_t'_ ..:..._..._. ----• -_ 1C:.__.__1.. ._-- _...............�__.....-- ---- I. .. ..�_._.._.—.. __..._.._.- --
<br /> i ' T
<br /> TOTAL GU£
<br /> OFFICE USE ONLY
<br /> • K,IpyaM -r,T'1 i!..,Y;!t i r', 5�1•i� �!.. :�r,�r•.r rl.al. I A�- f• 170'M;:7:'�rrtr 1'\_ ,(�:,'4• p
<br /> am ma�i< ,f IMIT.-qty,,; l ,.��',4� �J�!�� ��, �.
<br /> 3 evKV 5 M1.
<br /> cOt{P T LOC COCEU{ST r,OrE a'lOU0 DUE 1^AMOUNT R"'VD CHECK 0/CASH ROD DY l DATE P,EWYED _PE9n('s
<br /> � _,) .__._._....—. ._.. .__..._.....-.. -_..._._.._ ............. -_...-----._... I _ ......__... -"r. , •., w1w C `H�'lt q V r,•'y��a yJ'• 1M n � �f• •t �1.
<br /> F .;�, ,;,i.•.;u d b o ,htt">'.` :•r11,t: 3,.. .� 1 �i I F
<br /> �.t ti+,: �.t:..!. r r r r !rl•. ^r, t t ,�J r 1! 1,1} 1 t,s r r 1g� fil.4: rY. l
<br /> ,Aa. .nr, i�.r.••nC1,tyt:xtl. t'i t; 1.? '4.t ..r'• `-'�?�j;.,wl 1 ii!•t '�.n :i t y(t 1 F. '1�? '1,�3 G•I,.'11N'�Cr),1 �I�;L�i' I.I�I..dJ��t'4.1 t a
<br /> ( elf •.. G, I, lt•LL, h.tll ,t :a,.44. X. 1 .L.L.�'t1..�' ��' u i h4':.,7:•Ic�lA!
<br /> tidti'°I'.R��,;,i ili•'.��i :'.1;,:1 .tt::.''��a��i:"°i3:-i_._ I.:.�:•..rt7ar:"' ,4,••�::IS.11.1�.ql il.. Gi lli
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