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SAN JCI.UIN LOCAL HEALTH DISTCT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE RORKSHEET <br /> LITY/SITE <br /> FACILITY CONTACT NAME <br /> T STREET ADORESST71 1 <br /> SITE P ONE 1 MIT■ AREA coot <br /> Y WIT C� y 6S-S�3f1 <br /> —STC�C\STd f� ST TE i1P CODE I of ian'�s <br /> A APPLICANT/BILLING NAME a �S at Site <br /> P APPLICANT CONTACT NAME <br /> 1 M (LING AID SS <br /> A �' V G d APANT PIONE 1 WITH AREA Cao■ <br /> CITY333 <br /> �fTd!� T ► q 11�oP CODE APPLICATION <br /> CLO■UAE IN■TALLAf IOM, ETC. <br /> FACILITY FEE _ GLpse`1�� <br /> 1100.00 each SITE ADDRESS per YEAR <br /> j 1986 TOTAL <br /> I <br /> 1988 1989 <br /> V 4 <br /> E TANK FEE = 150.00 each TANK <br /> f t Tants _ _ Y (50.001986 <br /> A (wHipry 1 by lee for 1987 1988 1989 <br /> C eAch year applicable) <br /> I <br /> L STATE SURCHARGE = 456.00 each iAHK lsee CA HEALTH b SAFETY CODE Sec 25281 for applicability) 1 <br /> 1 <br /> i 1 Tanks s I COO 1986 <br /> Y tenter Tanks-- <br /> and year) 1981 1988 1989 <br /> C PERMANENT CLOSURE (Re <br /> eoval or Closure-in-place)— - <br /> L <br /> S CLOSURE FEE = 490.00 each TANK <br /> R if �1 Tanksa <br /> 190.00 <br /> / Fi� <br /> E <br /> TE � BANK <br /> OCKTON <br /> � <br /> 90-103VTOT <br /> FTacHT....... <br /> 1211 <br /> p pL CALIFORNIA CONTRACTOR LICENSE 3.1.5 C SA <br /> L P.O. R 500 STOCKTON.CAW R. S1301-0505 303 <br /> A PHONE m3,.N3-e553 23751 <br /> N PL. <br /> Ef <br /> REI PAY Q R�2A 4�- <br /> 6-A Lx c r 11t)o" DOLLARS <br /> DATE CHE12 CK NO. <br /> R TAI (\Z T, . 1/�' /o`oQ��fM�{./�} <br /> P TO THE V V �l LA/V ALJ J ti� l lG /` <br /> ORDER OF <br /> A PIT <br /> I -- STOCKTON SERVICE STATION EQUIP.CO., INC. <br /> R UNI <br /> Ivh <br /> FEE <br /> II.02375Jon 1: 1211010371: 2111 2SOSSI 601 <br /> OFFS <br /> SNEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK /CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> a3 �� - --7-r, X 3- <br />