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4•Pu irul) 1{1-N21 I <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT .. <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> Y/SITE MANE FACILITY CONTACT NAME <br /> QEET <br /> C-- ADDRESS SITE PHONE 1 WITH AREA costs <br /> _ Ev"E 4Pr�e L-1�anwvt as � �-6ao � <br /> JA <br /> IfY STAT FIP CODE I or Tanks <br /> hi cx �c1 �a0/ at Site u UiJ�JY>y Rcut7d _ <br /> PPLICANT/BILLING NAMEAPPLICANT CONTACT NAME <br /> oc�.� �r<rYl1' YK Fc.o,RFs <br /> AILI ADDRESS <br /> APPL CANT HONE 1 VAT" AREA CODE <br /> _, __ < �_7lr�-tea nc�n $Tpi )IP CODE i APPLICATION <br /> LC CH ��O/ LDE R INETALLA1tOM, [1E <br /> I — <br /> FACILITY FEE R 1100.00 each SITE ADDRESS per YEAR — <br /> A _ TOTAL <br /> C 1986 F 1987 1988 1489 <br /> T <br /> I <br /> V <br /> E TANK FEE R $50.00 each TANK <br /> F 1 Tanks s 150.00 1981 1988 1989 <br /> A feultipry 1 b 1986 <br /> y lee for I <br /> C each year applicable) 1� <br /> 1 f <br /> L STATE SURCHARGE R 156.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability) <br /> I _ <br /> tenter iiouI 1 Tanks E 156.00 1986 1987 1986 1983 _ <br /> Y nt and year) —�� <br /> C PERMANENT CLOSURE (Removal or Closure-in place) — <br /> 0 CLOSURE .FEE R 190,00 each TANK 1 Tanks s (90.00 <br /> S - f <br /> IT <br /> R <br /> E <br /> -� BANK OF STOCKTON <br /> <br /> <br /> <br /> <br /> <br /> <br /> PT _ _ <br /> LI SOA-SN N.UNION 9T. STOCKTON,CALIF. 95205 SA 23714 <br /> 1 P.O, BOX S09 STOCKTCN,CALIF. 95201-TINS <br /> M PHONE 299/i9F032 <br /> PAY F!� IhEv_aO� t� F� tl ,�i� v OLLARS <br /> DATE CHECK NO. <br /> R ess <cRrS <br /> P �l-�sgb3'7, q /�0" . uv <br /> To rI,E s ` Rf �� � t n <br /> A ORDER OF �� (A/�9'K.�ry„ si <br /> I STOCKTON SERVICE STATION EQUIP.CO.,INC. <br /> R <br /> 1 IIA <br /> SWEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD )CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> 7 �� 337,1Y <br />