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0 <br />SAN JOAUUIN LOCAL HEALTH DISTRICT <br />UROL .JND STORAGE TANK PROORAM - FEE IN)WHEET - , <br />F FACILITY/SITE NAME FACILITY CONTACT NAME <br />A <br />L STREET ADDRESS <br />TE PHONE 1 NIT" AREA tetE <br />T CITY (t <br />STAT ZIP CODE I of Tanks <br />A APPLICANTFIILLING NAME <br />APPLICANT CONTACT NAME <br />P <br />P-`3tz<?_...m•�—E�=\/_A9L._=35��sa.1i_�� <br />1_IS C Ur"f_. <br />M111.1NO ADQRESS <br />APPLICANT PHONE 1 NIT" AREA tate <br />- ---.. <br />0CITY. ` <br />C \,`� ^ <br />— <br />STAT ZIP'CODE TYPE of APPLICATION <br />2�jl-„ GlS[UR[, INSTALLATION, [TC. <br />FACILITY FEE - 1100.00 each SITE ADDRESS per YEAR <br />A- <br />1-1981— 1988 —1989 1 <br />E TANK FEE ' 150.00 each TANK <br />F 1 Tanks 1 (50,00 1986 1987 1988 1989 <br />A UuIUpT-y-1-by lee lar El <br />f each Year a Ilcable)-----J_ <br />... --Y - pD ----- <br />L STATE SURCHAReW - 156.00 each TANK (see CA HEALTH I SAFETY CODE Sec 25281 for applicability) <br />I 1 Tame 1 156.00 1986 1997 1988 1989 <br />Y (enter NiAit and year) I — <br />I i <br />[ PEP.MARENT CLOSURE (Resotal or Closure -In-place) <br />L... -- ----_- - - - <br />- -- RANK OF STOCKTON <br />�J�/��[�Ja(a�] COMMRNCl/1L RAVINOe TNA <br />\\ rr� RTOCNTON. EAYIONNI• <br />CIILIFOaM 11 CGNTPRCTON LIC6NC/LLI F.1001� Sll <br />BObB20 N. VMON BT., ETOCKTON. <br />STOCKTON CALIF. 1N01-0900 <br /> <br /> <br />26657 <br />TOTAL <br />NOIOL lM/YFOft •---•— <br />� d pp1-CARS .------•----- <br />'AY — 9 LATE CHECK NO. R <br />lo 930 <br />1RTON 5r gTOCKTON SERVICE STATION EQUIP. CO., INC - <br /> <br /> <br /> <br />OFFUF DTT 09(y <br />n <br />TOTAL Diff <br />