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5HN .IUAUUIN LOCAL HEALTH DISTRICT <br /> _ <br /> -T <br /> WROUND STORAGE TANK PROGRAM - FEE AORKSHE. <br /> IF FACILITY/SIZE MAME --- FACILITY CONTA I AAMC E <br /> R <br /> L STREET ADDRESS <br /> SITE PHONE 1 °ITN AREA CODE <br /> Y CITY SATE ZIP CODE 1 of tanks <br /> T 1F o2� at Site <br /> F APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> ____ />1/4 /tea F �Cm �f,� �pdilO �C[nlson) <br /> I MAILING AODP,E55 p n APPLICANT PHONE 1 <br /> /,/OC/ - / MITM AD[A COD[ <br /> p `7�r /LJ •,�ia�oc �') 206 <br /> N CITY l STAT ZIP'CODE APPLICATION <br /> FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR -Jf �_ TALUATIONTOTAL <br /> 1386 1987 13881 <br /> TJul <br /> 1 Do "� oo""• 1 ,2 ov a" <br /> I <br /> E TANK FEE = 150.00 each TANK — <br /> F 1 Tanks ( 1 150.00 1986 1987 1988 198') <br /> A (Eullipry I-by fee for -- 11211-ew <br /> I: each year appl a able) <br /> l5 50'a 1 DO o-0 <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25281 for applicability) <br /> I <br /> — ————— [== <br /> T 1 Tanks a 156.00 1386 1981 1988 1383 <br /> Y (enter iiiunt and year) _ <br /> ;:z—L- <br /> - — Valle Commercial Bank 13578 <br /> AAA TANK REMOVAL & DEMOLITION Y P.O.Box 9100 <br /> 4900 N. HWY. 99 NO. 206 931-6810 1031 Ewt Wxlerioo Road <br /> STOCKTON, CA 95212 Sm kWn,C.1B..ix 95208 00-3901/1211 <br /> PAY DOLLARS 17 <br /> TO CLQ <br /> THE <br /> ORDER J <br /> OF n r <br /> _ �— - - -- - -- <br /> - ----------- �_ _ _ <br /> t <br /> TOTAL DUE <br /> OFFICE USE OILY <br /> SVEEPS 1 COMP i LOC CODE DIST CODE AMOUNT DUE AMOUNT RCVD CHECK WASH <br /> �—//RCVD DYDATE RECEIVED PERMIT 1 <br /> /L x O S~/ / 0 7 <br /> x <br /> E? 7 <br /> 3 <br /> V f. I 1�61�1R9� <br />