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SAN J'TAQUIN LOCAL HEALTH DISYRICT <br /> UNDERGROUND STORAGE TANK FR06RAN - FEE WORKSHEET <br /> F FACILITY/SITE NAME n Willy CONTACT NAME <br /> TI STREET D�DRESS C SITE PHONE 1 """ AREA CODE <br /> 1� e IL t�'1 Q <br /> Y CITY (::�kAT IP COD 1 of Tanks <br /> 'it_ 95ac) at Site <br /> AA APPLICANT/BILLING NAME APPLICANT CONTACT kh <br /> 1 MAILING ADDRESS , ^ � no / APPLICANT PHONE 1 "'rN AREA CODE ' <br /> A <br /> N CITY T IP CODE TYPE of APPLICATION I <br /> TINETAt.lATim ETC. <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A -_...----- --- ----.—.—_ .______._ <br /> 1 1986 1987 1988 1989 <br /> V 4-yM $ <br /> E TANK FEE c 1150_00 each TANK — <br /> F 1 Tanks _ _ x 150.00 19 198 <br /> 86 7 1988 198 2 r <br /> A (EultipTy-1-by lee for <br /> C each year applicable) CIVWROIVA, $ <br /> I -- <br /> L STATE SURCHARGE - 156.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for ap Fy <br /> I — <br /> T 1 Tanks x 156.00 1986 1987 1988 1989 S <br /> Y (enter iiouit and year) <br /> 1 <br /> C PERMANENT CLOSURE (Reeoral or Closure-in-place) <br /> L — — -- — <br /> 0 CLOSURE FEE - $90.00 each TANK 1 Tapks...... x $90.00 1 O <br /> X I, -- - - , <br /> AAA TANK REMOVAL & DEMOLITION Valley Commercial Bank 13 210 <br /> 4900 N. HWY. 99, NO. 206 931-6810 r.o.B..97M <br /> 1031 East N ,H.Roed <br /> STOCKTON, CA 95212 St ekton�C ornia 95206 <br /> <br /> 1�_L <br /> THE SUM <br /> PAY C) �au� I 3 DOLLARS $ <br /> -1 <br /> TO <br /> THE <br /> ORDER <br /> M OFOQIJI <br /> I� <br /> 7,L <br /> COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CiH (il/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> v��mJ�o vfSfD "f"1i9 aDWlP9VrV�! 9u� 81' W'"Nu1 <br />