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SAN JOAQUIN LOCAL HEALTH DISTRICT .. <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET � ne, 0 y S <br /> (AGILITY/SITE NAME FACILITY CONTACT NAME d �� <br /> C faT�c Cci Fa3 e l <br /> I — <br /> L STREET ADDRESS SITE PHONE 1 WITH AAaA case <br /> I <br /> T <br /> Y CITY , STATE IIP CODE 1 of Tanks <br /> CQA Cn I at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> F. <br /> I MAILING ADDRESS APPLICANT PHONE 1 WITH ARK& cove <br /> i <br /> A <br /> N CITY STATE IIP CODE TYPE of APPLICATION <br /> I CLSSYAe• INOTALLATION. OTC, <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> — _ <br /> T 1986 1987 1988 1989 <br /> I i <br /> V <br /> E TANK FEE _ $50.00 each TANK <br /> F a Tanks ' _ _ 1150.00 L986 1387 1988 1989 <br /> A Oultipfy 1 by fee for -- <br /> C each year applicable) $ <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25281 for applicability) <br /> T I Tanks a 156.00 1986 1981 198 1983 <br /> Y (enter iiolint and year) ----- _ <br /> f <br /> C PERMANENT CLOSURE (Reaml or Closure-in-place) <br /> L -------- -- ---- <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Anks ( 1 190.00 <br /> S <br /> U <br /> EI BANK OFSTOCKTON <br /> j ! OcorrexnwL�=wvm w oa I.NIA aT <br /> <br /> <br /> p CALIPORNIA CONTRACTOR LIC"S9 20!10!C-!1.SA <br /> L 008-120 N.508 ST CK N, CAUP. CALIF. !RO! <br /> P.O. BOX /. STOCKTON�CALIF. 95201-0508 1 <br /> A vNONE z!!/laa-ela <br /> tl <br /> PAY I 1 f,) a n LARS <br /> R DATE CHECK NO. • ! ) <br /> E ,o THE Tb� c <br /> P ORDER OF _ l <br /> A <br /> I STOCKTON SERVICE STATION EQUIP.CO.. INC. <br /> R <br /> i <br /> SWEEPS I COMP 1 LOC CODE DIST CODE INOUNT DUE AMOUNT RCVD CHECK 1l/CASH RCVD BY DATE RECEIVED PERMIT t <br />