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SAN *QUIN LOCAL HEALTH DAICT <br /> _ UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> � NAME - <br /> 'i <br /> FACILITY CONTACT NAME <br /> ADD SS <br /> SITE PHONE t WITH AREA CODE <br /> ry STAT71P CODE t of Tanks rte+ <br /> n Get GS— at Site / <br /> APPLICANT/BILLING NAME APPLICANT CONTACT AME <br /> PT/ �ine Ccrh <br /> L <br /> G ✓ Q <br /> 1 MA[LIN DOPES <br /> C APPLICANT PHONE 1 WITH ARE cane <br /> A .?D 76 9, Ve - oap <br /> I CITY\S�° STAT ZIP-CODE TYPE of APPLICATION <br /> T / CLOG VAC. IMBTALLATION. CTC. <br /> A- <br /> FACILITY FEE = 11100.00 each SITE ADDRESS per YEAR TOTAL T — <br /> 1 1986 1987 1988 1989 <br /> I <br /> V f <br /> E TANK FEE _ $50.00 each TANK y <br /> F t Tanks _ _ x $50.00 1986 1987 1988 19 9 <br /> A (Aultipry f by fee for —_ <br /> C each year applicable) 9 11 <br /> f <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 25287 for'appli'cabiPi;ty); <br /> I <br /> I 1 Tanks z $56.00 19861987 1988 1989 <br /> Y (enter 5iouit and year. <br /> $ <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L _ <br /> R FEE = $90.00a-ch TANK1 Tanks / x $90.00 <br /> TELIC 1469 <br /> ENGINEERING TELIC ENGINEERING CORPORATION _ N? <br /> CORPORATION 287 N.Cardinal Avenue P.O.Box 2076 July s 1 g 9 <br /> Stockton,CA 95201 209/465-20001,)_ <br /> PAY NINETY & 00/ 100 * * <br /> TO J)OLT"I2S $ 90.00 <br /> THE f <br /> ORDER SAN JOAQUIN LOCAL HEALTH ,DISTRICT , 90414at1211 <br /> OF <br /> L E EN I CORPORATION <br /> PACIFIC STATE BANK / <br /> 246 East main St./Stockton,CA 05202 <br /> TOTAL DUE f JD, o0 <br /> OFFICE USE ONLY <br /> 1 <br /> SWEEPS COMP 1 LOC CODE GIST CODE AMOUNT DUE AMOUNT RCVD 6Et /CASH RCVD BY DATE RECEIVED PERMIT I <br /> WEEPS I . ......_._.-_-- C --- -- -- <br />