Laserfiche WebLink
unw a UAwU l tv LU AL HEALTH D I Pl'12I CT <br />RGROUND STORAGE TANK PROGRAM • FEE WORKSH <br />F FACILITY/SITE NAME �^ FACILITY CONTACT NAME <br />A �/P:tJi� D/" <br />I �-�` zDUiv �5c� <br />I <br />L STREET ADDRESS SITE PHONE 1 <br />1 ,ti+'—�u � WITH AREA CODE <br />Y CITY STA IIP CODE 1 of nks <br />,�s ?F, at Site / <br />A APPLICANT/BILLING NAME <br />Pte/ APPLICANT CONTACT NAME <br />P <br />L <br />! MAILING ADDRESS APPLICANT PHONE 1 <br />�� r..,/ M1TM AREA CODE <br />N CITY (JY '��S Z - <br />T ��_ STATPZIPDE TYPE of APP <br />6t000RE, AttwTtONTC. <br />SEIBOLD CORPORATION <br />P.O. BOX 728 209-948-2152--^ <br />STOCKTON, CA 95201 l <br />PAY TO THE S <br />ORDER OF_ <br />HEADQUARTERS <br />301 E. Miner Ave., Stockton, CA 95102 <br />2 <br />1EM0 ®%C <br /> <br />�J1195 <br />3 —/19 p ` <br /> <br />' DOLLARS <br />TOTAL DUE s /� <br />OFFICE USE ONLY <br />p.,, 1�. . %�I I I p it 1 rt n u tml n <br />n,. 1 I till ��, I I, 11 !r ny p I u1�1 i i11.1,!PI �� lil "OIINt 'I' I All.,xeyri <br />SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH RCVD BY DATE RECEIVED PERMIT 1 <br />