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T <br /> x <br /> / SATE JOAQUIN LOCAL HEALTH DISTRICT <br /> F177UNDERGROUND STORAGE TANK PROGRAM - FEE VORKSHEET <br /> TT/SITE NAME <br /> �j FACILITY CONTACT NAMEi�/9 ?;W <br /> ET'AOORESS SITE PHONE 1 NTTN AREA CORE <br /> SiRE <br /> - 1 ����5 'T�i9/Y� <br /> Y CITY O STATE IIP DE Itof <br /> fTanks Site <br /> o <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> �ToEL <br /> I MAILING ADDRESS vAYAICANt PHONE 1 NrTN AREA CODE <br /> A . <br /> B CITY TAT II OOE PPLICATION <br /> /�VTJ�.�� - 7i) CLOEYRE IMETALLAT ION, ETC. <br /> FACILITY FEE a $100.00 each SITE ADDRESS per YEAR TOTAL <br /> 986 —1981 1988 I f <br /> V- E <br /> E TANK FEE a 450.00 each iAMK <br /> F I Tanks ', : .50.ea RK <br /> 13BI 1988 1983 <br /> A (eultipTy(,by fee for Q <br /> C each year applicable) f <br /> I <br /> L STATE SURCHARGE = $56,00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> — -- -- — <br /> T 1 Tanks __• aa156,O0 a`1 1986 1987 `1908 I 1383 <br /> nil ed <br /> SEI80LD CW ( , <br /> .::. ��.Uri'%� �.r^�/•�— AANKOFStOC :`�.` .g0-103 <br /> � ✓r�-��-�i--�..� �"•'�n...r 9TOCKTON CACI �r-1211 <br /> 11640 <br /> ! dt <br /> --- <br /> -�•"�.r`v^���.�,-�,.f'ti. -�'�..i'�.��•M�. �'."'.�.'",,-� -y $ 400 <br /> r V <br /> .. " . �LutlAPONATION <br /> .. ..iii'�1i-��•."�'�!^�,�i•�,.��-�..w/�'.�.rr.-�v�. ..i�^.r., L/..__ �`::. <br /> AUTHORIZE081RNA7VRE _ <br /> ME03 �6401I' I: ic' ii01037►; 2irr�66755Tr� �n'OL <br /> .30.00/hr FEE = 135.00/hr FEE _ $35,00/hr 1 -y--- <br /> TOTAL DUE <br /> OFf(Cf Off ONLY <br /> SWEEPS i COMP 1 LOC CODE DIST CODE AMOUIlt DUE AMOUNT RrVD CHE /CASH RCVD BY DATE RECEIVED PERMIT <br /> s <br />