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�0 u u <br />SAN J[)AQU I N LOCAL HEAL DISTRICT .. <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />FACILITY/SITE NAME FACILITY CONTACT NAME <br />L STREET ADDRESS SITE PHONE 1 IIITN ARCA CODE <br />J k LA J\/ <br />Y CITY - <br />�. i T7,,\, STATE ZIP CODE 1 0l Tanks <br />at Site <br />A APPLICANT/BILLING NAME I APPLICANT CONTACT NAME <br />P ,)jLLI'TCnj-�' ' ICy;!Parr —,b c� / <br />I MAILING ADDRESS APPLICANT PHONE 1 WITH ARTA CODE <br />N CITY (( _ STATE 1-1 CODE TYPE or APPLICATION <br />I—,1TL'cLrAl'- C,� ; /�,� CLDwAE, IRETALLATIOM� ETC. �''ti'�''lL- <br />'— (( <br />C PERMANENT CLOSURE (Relloval or Closure -in -plate) <br />0 CLOSURE FEE = f10.00 each TANK 1 Tanks( _ x 190.00 1 90 <br />S -- -- <br />�..._ <br />U _-- <br />p <br />EI [���,�3 y�� BANK OF STOCKTON <br /> <br />_P CALIFORNIA CONTRACTOR LICENSE ]0910! C-61, SA <br />P.O. B N.X UNION ST., STOCKTON,ALIF. CALIF. 95205 <br />L P.O. BOX !OB STOCKTON, CALIF. 95201-0500 22777 <br />J (_) <br />A PHONE 209/066-8333 <br />PAY DOL S <br />DATETO T.E 4r CHECK NO. <br />E ORDER Oi _ , 5� (%Ini_ oc _l,��l\ ��(�—�/ K'l /11I <br />P. 411- QQ- 4' � - - <br />A STOCKTON SERVICE STATION EQUIP. CO., INC. <br />1 <br />I <br />SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT HCVD CHECK 1/CASH _.!_CVA BY GATE RECEIVED J —� <br />f :--- rw ..__....----...._.........._.._ ._.... <br />... .._�.... _._- ....._.. i� PERMIT 1 <br />I <br />