Laserfiche WebLink
s <br /> S JOAQUIN LOCAL HEALTH OSTRICT <br /> _.._.____—_•,— UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> L STREET ADDRESS - <br /> I SITE PHONE 1 MIT" ARG eno9 <br /> Y Y <br /> Zd�� �S <br /> CITc SINE �2(P CODE 1 of Tanks <br /> -- - Lat Site <br /> A APPLICANT/BILLING NAME - -- — -- ----_--___ <br /> P r' APPLICANT CONTACT NAME <br /> PIL <br /> c�GfLiE SG+ <br /> I MAILING ADDRESS — —'—'" -- — / egg' <br /> APPLICANT PHONE t MIT" AREA CODE <br /> p- _�' � -- o' <br /> NCITY f c/3Z. cJ�3' <br /> T {/�J� ST TE lip CODE TYPE of APPLICATION <br /> ..__._..—_!�(i S��CU•---"--_.–_--`_— �� a �// GAeM"e. INSTALL DN, ETC. <br /> ---- / <br /> FACILITY FEE 1100.00 each SITE ADDRESS per YEAR — <br /> A-..-...._. -- — — --- TOTAL <br /> C --- — <br /> T 1986 —1987 1988 1983 <br /> I — -----------——-- <br /> I _ — <br /> E TANK FEE = $50.00 each TANK — �� <br /> — <br /> F 1 Tanks z $50.00 — a <br /> 1986 — <br /> A (nultipTy-I by fee for 1387 1988 Fi 4 9 <br /> C each year applicable) — — '—� -- f— —' -- — <br /> I — ••jj�� v s <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH & SAFETY CODE Sec 2 N7 <br /> 1 — ------ _ _ �o ability) <br /> T 1 Tanks x 156,00 1986 1981 1988 ( 8g/ <br /> Y (enter aioont and year) _ <br /> C PERMANENT OSURE (Ren..al or Closure <br /> CL111 place) <br /> L -- — ------ — ---- — '——--- <br /> - SO CLOSURE FEE _ $90.00 each TANK t Tanksz 430.00 4 c <br /> --------- —._...-- -__�_-- ----- L. <br /> OERI <br /> ON THE MECHANICS RANK 90-203 <br /> (4 5 Parr Boulevard, Richmond,California 94801 RICHMOND,CALIFORNIA 1211 <br /> 255 Par <br /> (415)235-1393• FAX(415)235-3709 <br /> EFIICKSON, Inc. No, 70304 <br /> DATE CHECK NUMBER AMOUNT <br /> 90/05/14 70304 $90.00***** <br /> PAY***90***************DOLLARS AND **00*10ENTS <br /> PAY TO THE <br /> ORDER OF <br /> San Joaquin Local Health District <br /> 1601 E Hazelton Ave <br /> Stockton CA 95205 <br /> K VOID AFTER 90 DAYS i <br /> ORI INAL SIG URE R QUIRED <br /> 11107030411' r: 121 102036x: 4011100317 ?ill <br /> wuYu.M. - ryglM W.yPYm MWYwYIMVX•IMM WY,!' ,{pVN,MYYYYN u:o' -... <br /> rvMVAxlMp4NN,IWW 61Y 144YY,FYINIIM WyMYYMPYY11YpIIg14NIMl,y YYW'IYYM YIa <br /> 9UEEPS 1 COMP $ LOC CODE DIST CODE AMOUfIi DUE AMOUNT Rr,VO NECK /CASH RCVD BY DATE RECEIVED PERMIT t <br />