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SAN &QUIN LOCAL HEALTH DISOICT <br /> UNDERGROUND STORAGE TANK PROGRAM <br /> NAME - FEE WORKSHEET <br /> _ <br /> FACILITY CONTACT NAME <br /> .r: ADO SS r u <br /> t (�•n , c SITE PHONE 1 WITH AREA CODE <br /> ry y1 – O _ <br /> STATE llP CODE f of Tanks <br /> A APPLICANT/BILLING NAME G/t 03— at Site / <br /> P <br /> PC APPLICANT CONTACT AME <br /> I MAILIN ODRES — b r <br /> C Q <br /> A .'Z D 76 APPLICANT PHONE 1 NITN AREA COO. <br /> T clrr Dep <br /> STAT IIP CODE TYPE of APPLICATION <br /> ,.¢ 0 CLOO"E. INa TAII.ATION. ETC. <br /> FACILITY FEE T$10-0.0-0 each SITE ADDRESS per YEAR <br /> A <br /> C <br /> 19861987 1988 — TOTAL <br /> 1989 <br /> V <br /> E TANK FEE _ f50.00 each TANK f <br /> F t Tanks x 150.00 <br /> A (aultipiy"-( by fee for 1986 1987 1988 <br /> C each year applicable) 19 9 — <br /> L STATE SURCHARGE = 1156.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for ePGIi'cabil t f <br /> 1 <br /> T 1 Tanks x $56.00 ), <br /> Y (enter aiount and year) 1986 1987 1908 y, ., <br /> 1983 <br /> C PEP.MANENT CLOSURE (Resoval or Closure-in-place) 11 <br /> R <br /> TEuc FEE = $90.90 each TANK <br /> _— —- -- -— 1 Tanks <br /> ENGINEERING TELIC ENGINEERING CORPORATION 1�7 <br /> CORPORATION 267 N.Cardinal Avenue P.O,Box 2076 1469 <br /> Stockton,CA 95201 209/465-2000 July 5 <br /> PAY NINETY & 00/100 * k * * * * * * * * * � -1!) 89 <br /> TO <br /> THE �)OIJ,AItti S 90.00 <br /> — <br /> ORDER f <br /> OF SAN JOAQUIN LOCAL HE,ALTH.DISTRICT , , . <br /> • 90-01488211 <br /> L <br /> JEEN 1 CORPORATION <br /> PACIFIC STATE BANK <br /> 246 East Mein SIJStockton,CA 85202 <br /> OFFICE USE ON(y TOTAL OUE 11 <br /> 5'D, o0 <br /> SNEEPS 1 COMP 1 LOC CODE DIST CODE AMOUfli DUE AMOUHi RCVD T <br /> 9y- RCVD DY DATE RECEIVED PERMIT 1 <br /> a <br />