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SAOJOAQUIN LOCAL HEALTH I34TRICT <br />UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br />.... ...... --- -- ...— -- - — ._._�— <br />r FACILITY/SITE NAME <br />--- - ---- - <br />---- - -- .._._... <br />FACILITY CONTACT NAME <br />------------- <br />4 <br />/a.V.Y/---- <br />i <br />IXK Tn = tSD.DD eaih TANK .4 �a3 <br />F <br />A <br />L STREET ADDRESS <br />C <br />I <br />SITE PHONE t MIT" ARG caoR <br />L <br />T <br />Y <br />Y CITY <br />S�TE ZIP CODE 1 of Tanks <br />t Tanks x (90.00_ <br />at Site <br />x'+T�TCMIT/lllll NAME <br />--- <br />APPLICANT CONTACT NAME <br />F <br />ERICKSON <br />THE MECHANICS BANK 90-203 <br />1 MAILING ADDRESS <br />255 Parr Boulevard, Richmond, California 94801 <br />APPLICANT PHONE 1 MIT" ARRA Coue <br />S/3Z- 9v�s" <br />A <br />(415) 235-1393 • FAX (415) 235-3709 <br />N CITY / <br />T f�/� <br />STT <br />/A <br />ZIP CODE <br />TYPE of APPLICATION <br />CLCIMRE, INSTALLATION, RTC. <br />/^ <br />�/L <br />DATE <br />CHECK NUMBER <br />�Q _// <br />90/05/14 <br />FACILITY FEE = 1100.00 each SITE ADDRESS per YEAR — <br />- -- 1989 - - -- — ....- <br />A - — - -- -- ---1987 ----1--"-1"988 <br />--.. ---F--"1999 <br />1 1986 <br />TOTAL <br />-------- -- <br />------- -- <br />V - - <br />-- <br />i <br />IXK Tn = tSD.DD eaih TANK .4 �a3 <br />F <br />A <br />- — <br />1 Tanks_ _ x $50,00 1986 1987 1988 Fi 49@9 <br />(multiply 1 by fee for — f— <br />C <br />I <br />each year applicable) <br />L <br />T <br />Y <br />STATE SURCHARGE = $56.00 each TANK (see CA HEALTH 6 SAFETY CODE Sec 25ability) <br />1 Tanks x $56.00 1986 1987 1988 1 6V <br />(enter iioaot and year) <br />PAY***90***************DOLLARS AND **DD*iCENTS <br />PAY TO THE <br />ORDER OF <br />San Joaquin Local Health District <br />1601 E Hazelton Ave <br />Stockton CA 95205 <br />'WEEPS 1 I COMP 1 ILOC CODELDIST CODEI AMOUNT DUE I AMOUNT RCVD <br />K VOID AFTER 90 DAYS <br />I <br />�'/11f17V <br />—� <br />ORIGINAL SIGNATURE RIEGUIRED <br />RCVD BY I DATE P,ECEIVED 1 PERMIT I <br />- ------------- <br />C PERMANENT CLOSURE (Reaoval or Closure -in-place) <br />------- -- <br />-- <br />0 CLOSURE FEE = $90.00 each TANK <br />t Tanks x (90.00_ <br />G G E'er <br />--- <br />ERICKSON <br />THE MECHANICS BANK 90-203 <br />255 Parr Boulevard, Richmond, California 94801 <br />RICHMOND, CALIFORNIA 1211 <br />(415) 235-1393 • FAX (415) 235-3709 <br />ERICKSON, Inc. <br />No, <br />70304 <br />DATE <br />CHECK NUMBER <br />AMOUNT <br />90/05/14 <br />70304 <br />$90.00***** <br />PAY***90***************DOLLARS AND **DD*iCENTS <br />PAY TO THE <br />ORDER OF <br />San Joaquin Local Health District <br />1601 E Hazelton Ave <br />Stockton CA 95205 <br />'WEEPS 1 I COMP 1 ILOC CODELDIST CODEI AMOUNT DUE I AMOUNT RCVD <br />K VOID AFTER 90 DAYS <br />I <br />�'/11f17V <br />—� <br />ORIGINAL SIGNATURE RIEGUIRED <br />RCVD BY I DATE P,ECEIVED 1 PERMIT I <br />