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SANQOAQUIN LOCAL HEALTH DTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> ........... <br /> -.,_.._ _- <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> AC'D all <br /> L STREET ADDRESS n SITE PHONE # ITx H AREA CODE <br /> Y CITY STAT ZIP CODE # of Tanks <br /> at Site <br /> -- <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P <br /> 1 MAILING ADDRESS APPLICANT PH i WITH AREA CODE <br /> N CITY STATE ZIP*CODE ITYPE of APPLICATION <br /> T^ n - - -- - CIS 9 a INSTALLATION, CTC. <br /> FACILITY FEE _ $100,00 each SITE ADDRESS per YEAR TOTAL <br /> A........-.__.. ._.._...... _ -- - - - - �� - <br /> - -- 986- ---1987.._ �..-...1988 983...._.. <br /> E TANK FEE = $50.00 each TANK <br /> F t Tanks _ x $50.00 - 1986 1987 - 1988 — 1989 <br /> A (�ultipTy_f_by fee for <br /> C each year applicable) f <br /> I -- <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 4 SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks_^_ou-' x0 --� 1986— 1987 - --1988 — 1983 4 <br /> Y (enter aDnt and and year) <br /> C PERMANENT CLOSURE((Renoval or Closure-in-place) — -' <br /> L --- <br /> 0 CLOSURE FEE _ $90,00 each TANK t Tanks_____ x $90.00 f <br /> S'--- ---- — - <br /> U ... <br /> R T{ iN15 CMEnLN IS IN PAYMENT Ofi FOLLOWING'. <br /> E WELDON, WELDON i COWELL CONTRACTING 0 9 3 0 <br /> TE -P•0•-ROX 69 ��1 lOa;lee4 L1 nlctw�t[ (y <br /> HICKMAN, CALIFORNIA 95323 <br /> (209) 874-3722 -- -- <br /> P .PL FAX (209) 874-3723 CENTRAL BANK <br /> L --- WATERFORD, CA 95386 90.2067/1211 <br /> A r I L, f <br /> N P THE S U i 19C ./i I.11.!.!.,;:I bN)l L <br /> . . PAY DOLLARS <br /> -f��\ DA <br /> TE CHECK NO. M <br /> TO T <br /> AOUNT ^- <br /> R ORDEROF ��('% p � L11 AJ (lP tl I I --'J �O Z!� 9 1Q::. - <br /> P, T U . �( l <br /> E--- U _ � OVER $500.00 2 SIGNATURES REQUIRED <br /> A FIT <br /> 1--- <br /> R UN <br /> (W AUTHORIZED SIGNATURE <br /> FE - -- <br /> TOTAL DUE I ( - <br /> OFFICE USE ONLY <br /> J'JSWEEPS <br /> � HI!11181�V1iNNt COMP t LOC CODE DICODAMUNT DUE AMOUNT RCVD CHECK t/CASH RCVD DY DATE RECEIVED PERMIT t <br /> _.....!!VIHVIIHN!HIHNNHN)II!H�INHNII!IVHNHHIIHII!IIMiloHHNIII11"!I!!Nllmi•NHNHmVHNINHI�ININ�IN�1V NNNIVHPdII@NNVHNI!NliII!NuHINV INIINVH!��91NVHHHIVINNIVNII�IHIIIIIINNHHIIHNHNIINVHI NIINIIVI�fHiHII�RVIN,�HNNN�IHI�I.(� <br />