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• �-� A , : JOAQU Y.N LOCAL HEALTH
<br />UNtI! R�ROUND $TOPAaE tARY MOAN'- .y TEE VORMW
<br />FACILITYtrON1AC '
<br />tr tACILITYMI NAME
<br />t
<br />T
<br />tL.mL C "— d4tA 'oODs
<br />I $4E PHONE I 417M
<br />L ORO AMESS p5 —
<br />ZIP r,OJf i of
<br />Tanks Ri ICE
<br />Y CITY ..__ � gS014 a; Site
<br />—LOIi! .._... , j.. • �. _. � :$� $ , ......_ _. "APPLRANT CONTACT NANR
<br />A APPLICARMILLINO NAME
<br />:.� .. ,,_....�..w .._ .w..,•�:.-.�. ~.•-- P LiCANT - PNt1NE t
<br />1 NATLlN3 AaoREsS .,rte affil _60
<br />�'.�
<br />13_3% ' r ,. STA:E 2lF' -CODE
<br />TYPE ApMOTAL�a,HOh. a F ��1 {
<br />® N fid _ y_�,�'! �._
<br />TOTAL
<br />FACIlIY td£ $ 100,00 eaPh SITE tAobgtSj, Per YEAR
<br />A._.,.__. .,.... ...•...._ .." l985 497 980 i3B3 �_...r ._.�r--�.----^
<br />E TANI; rEE tyt$O,OO�eech'Al*�089
<br />f` 3� � •.._ ..... _ ...— .,
<br />r: ..... ..19f?8 • 1396 1__--•--,—.._ ...-
<br />118,
<br />F t tanks T5b, t`.c1
<br />A
<br />txulttpry `by tee ter,
<br />�-
<br />1NF�a TN � S�•F'FTp �b�C 2 cf�) !ar aG4tieabtlity9 .... -.~--
<br />L STATE SOnCNARGE - 13C b0 OR.
<br />tseatA - 1 — SP(
<br />a}
<br />tI #1+ank5 x 0 0 1996 T _ l9M _•.__-j--- — - _----�=.., _....�._ _ -T
<br />Y� (anter aeount and year)
<br />ft PERMANENT UOSURt ResovAl bt
<br />- L N�."�.;<
<br />C FL SURE FEE � 00,00 egth IA'k
<br />ip rE�spC�RARY CLtT5tll:E (Only 4116#d Of tt�e foruOYt-6 kuc,'yaa•�1
<br />E
<br />FEE 'JO® �6 -oath; i AP1Y,
<br />Cltla,JeCy
<br />[jkltl 11111 (insta1111ion
<br />e � �` �N£! � f EE
<br />d r
<br />9EfiA1R
<br />_.... _ .... r~ ..�_ _ .. __ ._._._ t_ _ ._
<br />•
<br />k13,14): REPAIR FEE " tll0{00�ea�h ��ANK
<br />? � � 1 as �l
<br />X
<br />�Pi _ .._,.. '•• hs ,# :r,® !4'l7 f4 P P'ald C.n. vi"'n S4i;Dltfal)`
<br />1r+�FtPING tfEt+tilRi LOWEIREM09AL (tees are ger E�e��, �! E _,__to—
<br />(i .-.,.. .._ .. a� t Fin r, IvISFEt '" i
<br />e'9�,Alli►fOR'lIE9 PREASE EVAvIIAtl�ll CO,s;s.PU +pit +NSil..i+a {enc 4Pp1leabl�l
<br />1 ,ir.ablei +when ai�Nll able• �.—
<br />vr.en avDP ,. .�.. � •• - •� -s
<br />FEE
<br />FEE - SsS,M1aht
<br />.w.
<br />h�
<br />TOTAL DUE
<br />�ftlCE U5E Gllty '� �
<br />j...l.pt�_"','' it { r.K, pr 111 !�"-91 'R. . ?{
<br />� , �N`:. . tB Ji t.:t.':Y�l,id�i °�', 'r "�' �i R'�fl,�,F •j " ,y Y �''ii n �ITi,''�� UC.�M16+, i'�9�y4N. �t•_.i,�,r.ls�a� _Pa p',,�.Gt��..Ilt �l�tli t�. - ��.
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<br />COn LO
<br />CODE DIST cOrl 00101 cis, i (..�
<br />, :EPS Q'
<br />aATc 6P�cE1rE0 PEQ++!
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<br />MMI,NOW25llP..j
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