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• v v <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> _ UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET_ <br /> Ir <br /> CILI FA /SITE NAME FACILITY CONTACT NAME <br /> 6 Aos f G . <br /> I <br /> L STREET..A9D S SITE PHONE k MIT" AREA CORE <br /> I `` <br /> T <br /> Y CITY AT IIP CDBE I of Tanks ` � <br /> — G at Sile �/� 6_7 <br /> A APPLICANT/BILLING NAME APPL NT CONTACT NAME <br /> P � <br /> P <br /> L �rirvr, o cam — D nS <br /> — <br /> I MAP AODR APPL NT P E MIT" •RE come <br /> N CITY ATE TIP'CODE PLICAL NUA 11 <br /> 011. ETC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR V TOTAL <br /> T 1986 1981 1908 I9B9 <br /> I f <br /> V <br /> E TANK FEE _ 150.00 each TANK <br /> F 1 Tanks s t50,00 1101 1781 1988 1909 <br /> A (multipTy l by lee for — <br /> C each year applicable) { <br /> I — - <br /> L STATE SURCHARGE _ 156.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25281 for applicability) <br /> I <br /> T I Tanks / 156.00 1986 1901 1988 1909 <br /> Y (enter iiiNt and year) <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L —� <br /> 0 CLOSURE FEE = 190.00 each TANK 1 Tanks a 190.00 <br /> 5 — <br /> TELIC �r <br /> ENGINEERING TELIC ENGINEERING CORPORATION 1�O 4357 <br /> CORPORATION P.O.Box 2076 <br /> Stockton,California 95201 209/465-2000 6- 19 <br /> ---__1990 <br /> PAY **Ninet & No 100* <br /> TO DOLLARS �*9() - (1 fl* <br /> THE <br /> ORDER <br /> S...J.. .Local .Hea-lth District <br /> L ZTC N &11 ��/Rpll <br /> PACIFIC STATE BANK <br /> 246 EAST MAIN ST,/Stockton,CA 95202 <br /> <br /> - OFFICE USE ONLy <br /> m affilvil <br /> m� � maam m� mmppp, <br /> SWEEPS 1 COMP I LOC CODE DIST CODE AMOUNT DUE AMOUNT Rr,VDCI . /CASH RCVD DY DATE RECEIVED PERMIT <br /> 3a a- `TD - 90 G,s� mO � B11 SB nmli mmORR Ott <br /> �lm . <br />