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r <br /> L STREiT ADDRESS <br /> 1 w SITE PHONE I NIr" ARBA coo. <br /> CITY ._� _ ............. ' t <br /> STATE ITP CODE I of Tanks <br /> ._...._Tlf`C c5-....._ •-----.- -•-----•-•-•----___._._.-. G q_ __...._ at Site <br /> A APPLICANT/AILLING NAME ____. _""""'— _ <br /> F APPLICANT CONTACT NAME - '" <br /> F Dow;d Kei t <br /> L ___ _._..___._.. _.___. . <br /> 1 MAILING, ADDRESS Wes}Ick Feu,► SeYU�� __._..__. _.._._ <br /> APPLICANT PHONE I NIT" AREA Coot <br /> STATE iIP CODE TYPE of APPLICATION �M•-MT-"'��--- <br /> LasvR. <br /> C r INSTALLATION. ITC. <br /> FACILITY FEE - 1100.00 each SITE ADDRESS per YEAR <br /> A ...___._ ___.._ _____ .__.___ <br /> . _._. .._.._._._........_ _ TOTAL <br /> T 1386 138) 1388 1383 <br /> I E TANK FEE 1.0.00 each TANt; <br /> _... <br /> F I Tanks _ x 150.00 1.38b .... 1381 -LA <br /> ____._._...__._.__.__._.._.._...._.....A (multiply-fby fee for 1388 1989C each ear a II tYPpcable. _.._ <br /> L STATE SURCHARGE = 156.00 each TANK (see CCA HEALTH k SAFETY CODE Sec 25281 for applicability) 1 <br /> T 'I�Tanks x 156.00 _ 1986 13810' <br /> Y (enter ii66ht and year) 1388 <br /> PERMANENT CLOSURE (Removal or Closure-in-place) <br /> 0 = 110-00 FEE CLOSURE <br /> • each TANK <br /> EXPLANATION <br /> <br /> SHAW'S MAINTENANCE 9766 <br /> 1845 FULKERTH RD. <br /> TURLOCK,CA 95380 ` <br /> ,AY 42' / <br /> iMOUNT S CHECK <br />-)F CHECK AMOUNT <br /> ATE TO THE ORDER OF ACCTS.PAYABLE DISC. OTHER NUMBER <br /> i <br /> $ rJ <br /> ICT <br /> _ � p <br /> ENVIRONMENTAI HEALTH DIVISION <br /> SPECIAL MIT <br /> CHECK VOID IF NOTCASHED W THIN 30 DAYS <br /> J <br /> ^ 1 <br /> GUARANTEE SAVINGS- <br /> 2000 GEER RD. TURLOCK,CA 95380 <br /> <br /> �U <br /> OFFICE USE ONLY IuInl DUE <br /> SWEEPS I COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK I/CASH RCVD BY DATE RECEIVED PERMIT I <br /> ..._�.r�_..... ._ .G J/ G . <br />