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SAN J^4QUIN LOCAL HEALTH DIS" ICT .. <br /> _— ----- UMsm1cGR0UN0 STORAGE TANK PROGRAM - FEE WORKSHEETm <br /> AGILITY/SITE NAME Ci r-cl, o{ rrcc7Crr u— FACILITY CONTACT NAME <br /> /=ir2:: S—enc;'c' y S PAYMENT <br /> I — <br /> L STREET ADDRESS SITE PHONE I YITN AREA comm <br /> T— //C ji��: - �r <br /> M Ay <br /> Y CITY ST TE IIP CODETlol,'Tanks7� e ENVIRa�dMENTAL HEALTH _ <br /> APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NWMITISERVICES <br /> E �:cr�>.a: oaf k'1r/�'<_ Srr.L.sTut1t\.T ?o �.�;•�� <br /> I MAILING ADDRESS APPLICANT PHONE 1d r <br /> / YITM AREA Cmm[ <br /> N CITY � --- STAT IIP COUP TYPE of APPLICATION CCC cf�2f� <br /> 1 c��.r"_lcT-�J� �S-aa. -- no[u[[. INSTALLATION, [Te. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR TOTAL <br /> A ..._--- --------- --------- <br /> T 1986 1987 1988 1989 <br /> 1 <br /> V <br /> E TANK FEE = 1150.00 each TANK <br /> F t Tanks _ _ x 450.00 1986 198T-171i A (mullipTy 1 C each year applicable)1 — — I <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 4 SAFETY CODE Sec 25287 for applicability) <br /> T I Tanksx $56.00 1986 1987 198B 1989 <br /> Y (enter iii5ht and year) <br /> IUOSPERMANENT CLOSURE (Removal or Clos ace <br /> CLOSURE FEE = 190.00 each TANK x 190.00 11 Cj/]TEMPORARY CLns(IRF (wR ,11K.. <br /> BANK OF STOCKTON <br /> <br /> 0 .To�KTeN, wuFowN\w <br /> QUI ICO�I.I 00 °11.. C'C,[�' 0 <br /> CALIFORNIA CONTRACTOR LICENSE]09109 C-61,SA 22776 <br /> �/L���/// /� <br /> 6 <br /> 808-"0 N.UNION ST.,STOCKTON,CALIF. 93205 )- / 1- <br /> P.O. BOX 508 STOCKT ,CALIF. 9 5201-0 508 G G <br /> PHONE 2094668]9] <br /> J <br /> PAY_, -DOLLARS . <br /> DATE CHECK NO x ' <br /> TO TOE \-VCJ �!!C\fC'{���JYL� �/�_ ✓ 1 Ciro <br /> S/ <br /> ORDER OF _, <br /> STOCKTON SERVICE STATION EQUIP.CO., INC. <br /> RDIBIAI <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCV BY DATE RECEIVED PERMIT t <br /> .........—— ..._._..._.._..... — ...._. ... — ._.. <br /> D O ivG I N 70.. ........j...aC1............ .�___ - -- - <br /> IQ �I�IB9�� <br />