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UNDERGROUND STORAGE TANK PROGRAM FEE WORKS <br /> • V <br /> F FACILGTT751TE�NAME -' - _..._..._. -_-r------_.:_:......_,__....:-.._...._............._.._. _ �.�• <br /> $FACILITY COZI7ACT MANE_- -- <br /> C <br /> L STEEET ADDRESS ---•---_--...._.,._.,._.._. <br /> 1 /p ?q` SI1E HONE r WITH AREA cool <br /> YCITT . Jra — - — <br /> •• � � ISrAFE� TIP CODE I oT Tanky <br /> - <br /> - <br /> at Site pK e r <br /> A APPLICANT/OILLIN6 NAME ----'-'- -'-' <br /> p � � APPLICANT CONTACT NAME <br /> F - I <br /> L 1�'[e X .__. t Mme..._._.. G...?.C�...._.._...._._.._...K!? <br /> I MAILING ADDRE�S, <br /> APPLICANT PHONE I WITH AREA cape/ <br /> R CITY - �G - . 7 -� to%�J� <br /> . c .. ` <br /> ............. - <br /> T ATE IP CODE - —" <br /> �aau APPL ICATIOH <br /> C ......._-_ --------- _ INITALL4rION, ETC. 4017 <br /> A FACILITY FEE _ $100.001 each SITE ADDRESS per YEAR, <br /> --------._....- ......-....__. _.... .....__._......._.. <br /> C - w _ —TOTAL <br /> r 1986 I 1981 19081 1983 <br /> t, T <br /> E TANK FEE _ $50.00 each TANK " ` - <br /> F trants _ _ : uo.Do - — <br /> 1y86 ` <br /> A (qultipfY Z by fee for 1587 1988 1983 — <br /> C euh-year applicable) - <br /> -- - --- T <br /> ......_.__..-- -- -- <br /> L STATE SURCHARGE _ $56.Oo each TANK (see CA HEALTH 4 SAFETY CODE Sec 25207 for aoolicahi it ) <br /> f — <br /> DATE INVOICE I '"AMOUNT <br /> <br /> <br /> <br /> 2735 TEEPEE DR. SUITE E 1 0 7 5 Q.- <br /> STOCKTON.CA 95205 1 vv <br /> 1209)948-6124 <br /> PAY 4-1 µo 1 O O — i OLLARS <br /> DATE TO THE ORDER OF Mo�R AweaR.T DISCOUNT CHECK AMOUNT <br /> oT„RR AecT .•AVA <br /> s � S'D Ate u..W to a.E..�'C-1 _ O <br /> E S ?. 14 WESTERN METER SERVIC C. <br /> UNION SAFE DEPOSIT BANK <br /> ,STOCKTONCALIFORNIA <br /> ' I I <br /> I- I <br /> ff$30.001hr, <br /> /CLpSOP,E/P.ENOyAI (fees are pet hnur, un1EuE one hour to'beq on plan suhgjttaUT <br /> _ _ELEASE.EVALUATI'ON COIISTRUCTION INSPECTION —ble) (vhen applicable) SAMPLING INSPECTION <br /> " (vhen applicable) <br /> T. ' <br /> FEE = f35.U0/hr� FEE <br /> I <br /> OFFICE USE OR(Y TOTAL DUE <br /> !fill"ac1VT19NIV111W1N,!VR0111a991flMBfl696VUI!B°VIII!IIflflIV!11V11V.911flIIIIVGflflI!VIIII!IIVVIIfiIiiVVVU VI!IINIVIIVIIVpI01iIIflIVIIVI!flVlll!MGIINV11flIIB VV�VIf�IPVI�f@6� <br /> SWEEPS 1 COMP I LOC: CODE DIST CODE AMOUNT DUE ANOUHT Ilryll CHECy. CASH Roll DY DATE RECEIVED PEenli 1 <br /> E13191@fl41�,RVIVRIP?1111@i?II !1111141,111091!wll!l9!.i�Vl.'fi!VBV9RV1199111!flllllfl fl!R!RflIIVEVE01WIflWII�VRfli� a99f� .IP�VVPf� 9� It y� <br /> g - -- <br />