|
SA1� ,xQI Ll i i LOCAL:, HEALTW � r S'TR 1 G7.
<br /> .- _. :..
<br /> UHT3ERCnOUNG &TOP,AuE"T1,PIX PROGRAM FSE l{ORKSNEE I
<br /> FACILITY CONTACT-11A -
<br /> �F FACILITY/SITE NAME
<br /> H,6 I?o z> D P-16K- i
<br /> SITE PHONE 4 41 TH Aii;A rQGC
<br /> L STREET ADORE$, c5Z_ CS I
<br /> 1 13 _.------ .,_... _ - — - -
<br /> Y CITY STATE _ lip WE I,oi Tanks
<br /> .10
<br /> A�APPtiCANT113llliNG NAME �� r- - -_ ���T I-APPLICANT CONTACT NAl1'r_
<br /> I
<br /> G
<br /> P
<br /> �f613 _x ifs �Sx�GIAT ES MILK- LE�( _
<br /> Inll I}i"v AGOP.Ec, .----._.�— APPLICANT PHONE # WITH AREA caul
<br /> [STATiZIP'COpE -�TYPE o[J Y Ll� 955?-� ICIQEVRC !?!3.Tn�lRTi arc,
<br /> +�f ACILf TY FE£ = ii00 0t:'pach SI iE AObRESS Per 'SEAR r_ ._._TOTAL._--------
<br /> Y1937. - _.13G(?_.._� T 1983 I���)�.•G,, _.��.
<br /> LOO o�
<br /> V .—
<br /> E TAl{K rE£ = 1%00 each TANK
<br /> iE } _t.ank..s_..-�_......_.......-.h.– ._.---'1387..,,..J'_...._ °88 _..._lc�8y C)90
<br /> yi -bp tee for utlpt
<br /> - — -
<br /> -
<br /> t; each year aaplkable)
<br /> t
<br /> GE�= l5b.G0 2d<it TAN}; (Set CA HEALTI & SAFETY 004E Sec 2S28J_Eor zp9licablli:y)
<br /> L STATE SUPCHAR
<br /> TI..1_•,a:tF53-_'r ,6.,.0�.-----... .r---•��66 •--T_.......X9.,7 _._. 1 t�9 - -.•� � 1,e3 .... _ -1990, _.. _.�...
<br /> Y (epter d,bount and year) �....... •_f- -"----._._.._ i _..._...
<br /> I;TPERMANENT- CLOSURE (Rem4l or. C1•tsvrc_i1-P14_.0 ._ __�...__• __ �^ •__. ____� . .,._ _T_ __._.- Y�T---------�_____
<br /> ICLOSURE"FEE = b40,00 ei,,n TANY. _C TattkS_3ry x t30.DC ._��••T a10:05 _--
<br /> 1 f ad t)dE''t i Z4^!� uo to to ears) -
<br /> F TEMPORARY.CLOSUFE Q10ty all ? - ,r ----- .._y.._�.. -
<br /> EI•----_.+......__--•---•��-•-•--•-•---. ..
<br /> �TEhrORAPY CLOSURE FEE 8Su,00 fact+ TANK
<br /> (P PLAN CHECK (Installation or Repair) _. _: - ' ._.__�_._.....- - �- --•--.._..m...��_ -- - � _ 1
<br /> INIPLAN. CHECK FEE - s;0,00 tact: 5116^:IS51(rt{�tE;t!ii:SSIT�{^__.._...._,---•-•.__.__ -- .._----_ ...�_ ___..� _ ._ _`__
<br /> PEPAIR
<br /> 1';i TANK REPAIR FE; - $.110,00 Wh TAM _ _........�..# lznls._--.., x �11a •�, _ -.--- �- �- .._. _ _.._
<br /> IiIP1P'IHG PEPAIVCLOSURE/REIVAL (Fees ve per 1/m.rr, ainSfla�-oTQ h4s> 'Orbe p3td or, plan subrsik� -_-
<br /> I. _........._ - _- ' -..._._....._ --._._. __._ -- -I
<br /> „1i;'!AI}THORII:O QEIEr`.Sf EVA;UP.T(Jti CO{i5TRU1;TTON 11i5PEC[ICN SA'it'l;}iG 11iSPECTI N
<br /> j (uhen a �iica�ie? iShen .ipplicab}e) _...__..
<br /> T l
<br /> (when app,ilt�?hf:e) --
<br /> j FEE
<br /> TOTAL DUE
<br /> oFFlcf USE 091Y yr
<br /> �xf r:C-• MAR tY ra rJn�q,.rRtl:�(I(;y;l;�' P�'�f
<br /> r.. sf,LM1;,, �a1' ;�.^ �"1ii! ' 1�lrlta;`tYltl' e r I "i '- ¢.I: i I ! 1` a u,:
<br /> 1k'1' J _ #n7 a�r�( ATE i i��.���i � I p, is
<br /> C...w '1,{ ?�"C4'Ut ww_R rn.w iR hV'
<br /> n ' y t �' ECK 51 ASN F,VG BY DATE P,ECE1dEG PEFIIIT.. # _
<br /> a ! SuiEPS # �OKP # LDC C CE DIST COLE A:.DJNT DUE AMOUNT R-,d0 �N_.'.._.._� ..... _�.._._....._ �--...__......_�_....... �..
<br /> ,�J _..._._.....-.—._ ._.. .__..._....... _.......... ............ ._-:._'_—_'_ _... � ..., �.... F'..', n 7�' ,.'r .._C tl l� !'�"h. .�{7:�� ATM• f4 .'w�_F—_.'f �j.
<br /> : .,,.Aq;
<br />
|