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{YJR.EA0j FACTS jTY ,, <br /> FAC 1 Li TY <br /> � <br /> { AD F <br /> , r�,�Tv.t►�!: llllllRF&Cxz:,1l,.. ,. ,''` , ' • . ' prr , <br /> ' II •-/�aO��y.Ga.YaM l��.til --�- .. ..... _ ' 1 • • <br /> � + ''......_ .. .., .... .. 1, 1. ... ..1. <br /> �' RICH- MART <br /> _- M TNORPf, WS RIOuTon OF QUALITY PHoDUCT$ <br /> 3 `� aea•s,76 4a: 4sn19985 <br /> �.] --• _ ( 361 NQ. U6CKMAN HOAR, P.O. 60X 35l <br /> LORI. CA A524f �II <br /> ^0357 f <br /> ;� ' PAYOU 1d5 <br /> •i�� i � •ur.l. � ._ -- --- t TU THE / � ..�y _ ��� 1211 ��� <br /> Or{Dt{{4F O� - r, <br /> BANK of= <br /> STO KION IQLLARS �I <br /> I E{ Loo[prr'ICt I <br /> I IF rw[St.,LW <br /> 1 A 45140 <br /> s, <br /> We <br /> I� f Iff <br /> !�•- l <br /> 12 l 10 l03 lis 2 310. <br /> lit <br /> �s' `Pe�aanent CI.OSU e1" tank) <br /> Underground Storage Tank in Wbi <br /> }storage has ce ere �h <br /> ,. ., aced :rind wig the Owner/operator has no intent <br /> " <br /> :Of re-using -tank, <br /> j <br /> f, Et'..�.� Permanent Closures x $90) <br /> lan Check Fee $30, —�— <br /> f <br /> Total Humber of flanks r <br /> Total Fee Due <br /> E <br /> b <br /> ykecall :fees payable to San .laa uin Local Neal th t}l' <br /> strict, Enclose this worksheet* <br /> !ith ',your check <br /> EXAMPLE - Annual Fee for Faci i i ty wi th 4 Tank <br /> s ( 1 regular. 1 unleaded s <br /> 1 supreme. l wd�to oil ) <br /> Existing. <br /> laQ <br /> g FaciliCy b 1st Tank . <br /> $150 <br /> { b. 3 Additional Tanks x S50 150 <br /> k <br /> 2. State Surcharge, 4 Tanks x S56OW'I224 <br /> w~��q��� , <br /> Total Number of Tanks 4 <br /> Total Fee Due $524 <br /> [h Closures will be conditioned. Contact a tie <br /> ,? alth Ofstrict <br /> I� �� Representative'. <br />