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SAN JOAQUIN LOCAL HEALTH DISTRICT <br />f UNDERGROUND STORAGE TANK; PROGRAM - FEE MORKSHEET <br />F <br />A" <br />FACILITY/SITE NAME - � - <br />FACILITY CONTACT HANE <br />- <br />A <br />C <br />IF— <br />I <br />l <br />STREET ADDRESS �� �. <br />�- -, f��!%� � m.� <br />r <br />S If PIID I MIT" AREA cool <br />1 <br />v <br />Y <br />CITY]'ST <br />T .IPOOE <br />1 0 Tanks -� <br />at Site 7 <br />c <br />1986 <br />A <br />APPLICANT/BILLING NAME <br />APPLICANT CONTACT NAME <br />198'3 <br />--- - <br />C each year applicable) <br />I <br />L <br />I <br />MAILING ADDRESS <br />AP (CANT NONE 1 MIT" AREA coot <br />N <br />CITY <br />STAT II?'CON— <br />-0 . PPLICATION <br />T 1 Tanks x 156.00 <br />Y (enter mount and year) <br />1986 <br />ETc _ <br />FACILITY FEE : {100.00 each SITE ADDRESS per YEAR _ <br />~ - <br />�YTOTAL <br />A <br />C <br />1986 1981 1988 <br />1589 1- <br />1 <br />v <br />{ <br />E TANK FEE • 150,00 each TANK <br />F 1 Tanks x 150.00 <br />A (oultipfy"l'by let for <br />1986 <br />1381 <br />� 1988 <br />� <br />198'3 <br />--- - <br />C each year applicable) <br />I <br />t <br />LSTATE SURCHARGE = 156.00 each TANK <br />Isee CA HEALTH II SAFETY CODE Sec <br />25281 for applicability) <br />T 1 Tanks x 156.00 <br />Y (enter mount and year) <br />1986 <br />1981 <br />1308 <br />- <br />1383 <br />— ---- <br />— -- <br />t <br />SEIBOLD CORPORATION <br />P.O. BOX 728 • STOCKTON, CA ♦ 95201 <br />BANK OFF STOCKTON <br /> <br />012259 <br />w7 <br />C <br />PAY <br />�-� �y�- v <br />TO THEPL �• <br />ORDER <br />OF <br />rc[�- /JJ.UVIIII <br />�J TOTAL DUE <br />OFFTct ost oily - <br />SUEEPS1 COMP 1 LOC CODE DIST CODEJ AMOUNT DUE AMOUIS RCVD CHECK I/CASH RCVD DY DATE P,ECEIVED PERMIT I <br />1C1 CF�rtIE' lo` Ul 7�_ _. _...._ ...._. ._ <br />