Laserfiche WebLink
SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAMEn FACT ITY CONTACT NAME <br /> I h/C/>pr- a/h ) 10hS � 1..0 , �1 <br /> 1 STREETfflR s4 �L Q SITE PHONE t t M "'A Co[[ <br /> Y CITY ` 1� SAT9 11a�D t of Tanks ' <br /> 5 ak Site <br /> A APPLICANTAILLING NAME AP LICANT CONTACT NAAME <br /> fl oc J�c�,�, --- —P-1, -i L <br /> I MAILING ADDRESS 1 d7 � no / APPLICANT PHONE 1 YITM A[[A coo[ ' <br /> N CITY /�x1a�T IP CODE TYPE of APPLICATION / <br /> Il/` 1 (M[TALLATIOM, [TC. <br /> FACILITY FEE a $100.00 each SITE ADDRESS per YEAR l b I� TOTAL <br /> A ----- <br /> C 1986 1987 1988 1989 <br /> T <br /> v Ytij s <br /> E TANK FEE [ $50_00 each TANK <br /> F t Tanks x 150,00 1986 1987 1988 198 go Y <br /> A (multipTy 1-by fee for <br /> I each yaar applicable) } R0 f <br /> STATE SURCHARGE [ 656.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for ap Hf <br /> T 1 Tanks 1 156.00 1986 1981 1988 1989 S <br /> Y (enter iiouit and year) — <br /> t <br /> CPERMANENT CLOSURE (Removal or Closure-in-place) <br /> L ._. — <br /> 0 CLOSURE FEE a $90.00 each TANK C Yants x $°0.00 1 <br /> AAA TANK REMOVAL & DEMOLITION Valley Commercial Bank 13 210 <br /> 4900 N. HWY. 99, NO. 206 931-6810 P.O.Box 9100 . <br /> 1031 East W.UA.Road + <br /> STOCKTON, CA 95212 Slo klon,C ornia 95208�� <br /> 1 <br /> p0 <br /> PAY THE SUM ,!ii. C) <br /> l^14" D O L L A R S $ <br /> TO •� I; <br /> a <br /> THE <br /> ORDER <br /> OF e <br /> SVEEPS t CC'i` LOC CODE DIST CODE AMOUNT DUE AMOUNT PCVD L�NECK�CASH R VD BY <br /> � IRS M. <br /> w , <br /> VD BY DATE RECEIVED PERMIT 1 <br /> a _ L9 b 2 v ao <br /> �77Nvma 20 ± So <br /> s^Wq m'I 71 <br /> LIMA= JtlNIRONAIR '�JM:p dJT1IlxYWC�Uq¢ T ,, a rt. '.A e�".;'1"R!r. 91f <br />