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SAN J'OAQUIN LOCAL HEALTH DISTRICT <br /> F FACILITY/SITE NAME UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> AA' <br /> FACILITY CONTACT NAME <br /> C Kooyman Trucking, Inc. <br /> IJack Hill <br /> L STREET ADDRESS <br /> I 1340 West Charter Way SITE PHONE t WITH AREA coot <br /> T 209 463-2500 <br /> Y CITY STAT <br /> Stockton ZIP CODE 1 of Tanks <br /> C <br /> A APPLICANT/BILLING NAME a 95201 at Site Two (2) <br /> P APPLICANT CONTACT NAME <br /> F Telic Engioeering• Corpon orati <br /> L Thomas D. Franken <br /> I MAILING ADDRESS <br /> C P• 0. Box 2076 Stockton, California 95201 APPLICANT PHONE 1 WITH ARIA cape <br /> N CITY 209 465-2000 <br /> T Stockton STAT IIP-CODE PPLICATION <br /> Ca 95201 claRUA E, erA��ATIpH, crc. Closure <br /> A <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> i 1986 1987 1988 89 TOTAL <br /> 19 <br /> I <br /> V <br /> E TANK FEE _ $50.00 each TANK $ <br /> F 1 Tanks _ _ x 150.00 1986 <br /> A (wltipfy I by fee for 1987 1988 1989 <br /> C each year apph able) <br /> I $ <br /> L STATE SURCHARGE _ $56 <br /> 1 .00 each TANK (see CA HEALTH I SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks x 156.00 1986 <br /> Y (enter aiount and year) 1987 1988 1989 <br /> t <br /> C PERMANENT CLOSURE (RefiOYal or Closure-in-place) <br /> L <br /> 1 Tanks---2• x (90.00 <br /> TELIC _ f 180.00 <br /> ENGINEERING TEL IC ENGINEERING CORPORATION - <br /> CORPORgTION Lic.No.569559 �T -- <br /> UNDRED <br /> 287 N.Cartlinal Avenue P.O.Box 2076 lr 11 3001 <br /> PAY ONE H <br /> Stockton,CA 95201 209/465-2000 <br /> EIGHTY 6 00/100 * * SPp��19 89 <br /> THE <br /> I oeoeH rHOLE 1I2S 180.00 <br /> OF - <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> <br /> L <br /> PACIFIC STAT IC N N PORATION <br /> 246 EAST M /Sto <br /> AIN ST E BANK <br /> ckton,CA 96202 <br /> <br /> OFFICE USE ONLY <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD / ) <br /> _ NEW 1/CASH Rr,VD py DATE RECEIVED PERMIT 1 <br /> 5 <br /> i <br /> -f --- -- <br />