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SAN JOAQUIN LOCAL HEALTH DISTRICT • <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> f FACILITY/SITE NAME �- <br /> A FACILITY CONTACT NAME <br /> C <br /> L STREET ADD SS <br /> I < L� SITE PHONE YITN AREA cc <br /> Y CIT <br /> S A E TIP CODE 1 of Tanks <br /> A APPLICANT/I LL NAME 7 _ al Site UNC <br /> P ...-..--`------ APPLICANT CONTACT NAMEF. -- <br /> 1�. q <br /> I MAILING AD ESS I — <br /> �.—...___._ —__- APPLICANT NO E 1 41TH AREA coca <br /> l <br /> A --T-��A�W D�—_.---- .� J of <br /> N rli ._. <br /> 1 -- �C � —�—'— 1A E TIP'CODE APPLICATION <br /> MErelLAtloN, [re. <br /> A FACILITY FEE__1100,00 each SITE ADDRESS per YEAR _5 — <br /> _ _ <br /> C <br /> 1986 - f TDTAL <br /> 1987 1988 E 1ANK FEE + 150.0 -- �... — — _ <br /> _ 0 each TANK <br /> F I Tanks s 150.00 — 1986 1981 1988 1983 <br /> A (eulllply-1'by lee for — — <br /> �: each year applicable) ��`` --- <br /> - _ --- <br /> L STATE SURCHARGE = f56.00 each TANK (see CA HEALTH L <br /> I — _ —_ SAFETY CODE Sec 25281 for applicability) <br /> T I Tanks a 156.00 1986 1381 — — <br /> Y tenter iiiuit and year) _ 1309-1383 <br /> C PERMANENT CLOSURE (Redaral or Closure-In-place) _ - — <br /> L __.— -- ---- <br /> 0 CLOSURE FEE a 190.00 each TANK — <br /> S . 1 Tanks 7 s 430.00 4 — <br /> CRISP TANK TESTING 1837 <br /> P.O. BOX 30487 831-1828 <br /> STOCKTON, CA 85213 <br /> _ �1 <br /> PAY TOTHE (�1__ _yU -- <br /> �� 191 <br /> 1 ORDER OF <br /> LLARS '— <br /> Valley Cumak9700al Bank <br /> P.O.Ro*8700 <br /> log'Eat WiterboRoad <br /> FO l <br /> 8f?n*b4 CAilto B6Y0 <br /> 2 <br /> OFFICE USE oAtr IYIAL uuC <br /> SWEEPS I COMP 1 LOC CODE DIST CO, 1MOUNT DUE AMOUNT R00 CII r,K I/CASH ANDY DATE RECEIVED PERMIT 1 <br /> T_.0 ._ 0-3 <br /> r3J i Q/ r!—Z,-76 <br /> . <br />