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SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> dbGROUND STORAGE TANK PROGRAM - FEE RORKSHE <br /> FACILITY CONTACT NAME <br /> L STREET ADDRESS SITE PHONE 1 WITH ARCA COOK <br /> T—' .x'17"'7 .S'- l' <br /> Y CITY >> STAIE IIP CODE 1 of Tanks / <br /> C J2� at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> L14 Z, <br /> I MAILING ADDRESS <br /> — '�( — <br /> C LI DO APPLICANT PHONE 1 WITH ARCA Coee <br /> A 206 <br /> N CITY <br /> T STATE IIP'CODE APPLICATION <br /> __._--_—_—_ --`---- -- CLOSURE INSTALLATION, ETC. <br /> FACILITY FEE = 1100,00 each SITE ADDRESS per YEAR <br /> A —. _ TOTAL <br /> 1 1906 —'" <br /> T _ 1987 1388 1983 — <br /> E TANK FEE = $50-00 each TAN' ��n-- �` 1 <br /> k <br /> F I Tanks ( 1150.00 i 1986 1387 I98B _ <br /> A (eultiDiy 1 by lee for _ — V�I9B9 <br /> C each year applicable) <br /> I 5� $ /Oct ° <br /> I STATE SURCHARGE _ $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25287 for applicability] <br /> 1 _� _ <br /> T I Tanks a 156.00 1986 1987 1388 1383 <br /> Y (enter iiiiit and year) <br /> AAA TANK REMOVAL & DEMOLITION Valley Commercial Bank 13578 <br /> 4900 N. HWY. 99, NO. 206 931-6810 r P.O.Wa13�r rl o <br /> \V Ic31 E�tP.O.Wa4d00 Road <br /> STOCKTON, CA 95212 BWckon,Cniifornia 95208 <br /> 90.3907/1211 <br /> J 19� <br /> PAY 3 L ' ' �l r/� DOLLARS S4!�L <br /> r <br /> TO �jJ ccs <br /> THE <br /> ORDER <br /> OF <br /> ----- - _ r..__ �_- - •oma.-.�.nrL--------rFEE _ {95 o0lhrr $ <br /> $ C <br /> Dff►C[ USf ONLY TOTAL DUE <br /> �W01'.1 1EMUDWII i ."�77�8�Ii S�WV��f�JGl�l9�.I'w MUMMOME <br /> SNEEPS 1 COMP 1 LOC CODE DIST CODE AMOUNT DUE AMOUNT Rr,VD CHECK 1/r,ASH RCVD BY DATE RECEIVED PERMIT I <br /> ' 1 A ���PV � GW /L s 6 C n 7T - <br /> FI 9RfVTS�� Ib a a�ua� �uu�m rar�uii woa� as� � <br />