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ynlV JU lulu LUt1AL HLALTH DISIt '3I <br /> UNDEMi OUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME <br /> A FACILITY CONTACT NAME <br /> C - <br /> I v <br /> L STREd ADDRESS Irzev <br /> I SITE PHONE 1 (with Area Code) <br /> T <br /> Y CITY STATE ZIP CODE I of TANK'S <br /> at Sike L <br /> A APPLICANT/B LING NAME <br /> f APPLI T CO ACT NAME <br /> Al2t o <br /> L Lr / <br /> I MAILING ADDRESS <br /> C APPLICANT PHONE 1 (with Area Code) <br /> c D <br /> A <br /> N CITY STATE 7 P CODE TYPE of APPLICATION <br /> T Cell (Closure, Installation, etc.) <br /> FACILITY FEE _ $100.00 each SITE ADDRESS per YEAR <br /> A TOTAL <br /> C 1986 <br /> f 1987 1988 1989 <br /> I f <br /> V <br /> E TANK FEE _ $50.00 each TANK 'A <br /> v. <br /> F 1 Tanks ' $50.00 1986 1987 1988 198'3 ES CT <br /> f ( ultipiy-1 by fee for 44'V <br /> each year applicable) <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH k SAFETY CODE Sec 25287 for applicability) /VVy ) <br /> 1 <br /> T I Tanks x $56,00 1986 1987 1988 1989 P NTq� <br /> Y (enter iiouit and year) <br /> C PERMANENT CLOSURE (Resoval or Closure-in-place) <br /> L <br /> 0 CLOSURE FEE = $90.00 each TANK 1 Tanks-y- x $90.00 $ <br /> P.O,BOX 588.7237,COCKT RANO BEACH, <br /> No. 009249 <br /> P.O.BOX 7237,CAPISTRANO BEACH,CA 92624-7237 Valley Commercial Bank <br /> NORTNCAL P.O.BOX 214608,SACRAMENTO,CA 95821 P.U.Bo.97M <br /> CONSTRUCTION 1031 Eut Waterloo Road , <br /> Sl IkWn,CalRornia 95208 <br /> 01/05/89 009249 <br /> , <br /> ******THREE HUNDRED AND SIXTY DOLLARS 00/100******* $ 360.00 <br /> PAY TO 1 <br /> ORDER <br /> OF: SAN JOAQUIN LOCAL HEALTH DIST. <br /> AUTHO I DSIGNATURE <br /> LEEPS 1 COMP 1 LOC CODE EC DIST CODE AMOUNT DUE AMOUNT RCVD 1/CASH RCVD 8Y DATE RECEIVED PERMIT I <br /> 63b Q7rrGz3 ; ,Ao' %6 <br />