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SAN JOAUUIN LOCAL NhALI " UADIMAL. r <br /> WROUNb STORAGE TANK PROGRAM - FEE WORKSHEE 0 <br /> IFFACILITY/SITE NAME FACILITY CONTACT NAME <br /> A <br /> cl California Water Service Company Mike Fowler <br /> I <br /> L STREET ADDRESS Wilcox Road SITE PHONE 1 with Area Code) <br /> 1 (209) 464-8311 <br /> T <br /> Y CITY Stockton • STATE IIP CODE 1 of TANK'S <br /> CA 95205 at Site 1 <br /> PJAPPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P California Water Service Company Mike Fowler <br /> L <br /> C MAILING ADDRESS 1602 E. La Fayette Street APPLICANT PHONE 1 With Area Code) <br /> A 209 464-8311 <br /> N CITY STATE ITP CODE TYPE of APPLICATION <br /> T Stockton CA 95205 (Closure, Installation, etc.) Tank Removal <br /> A FACILITY FEE - 4100.00 each SITE ADDRESS per YEAR TOTAL <br /> C 1986 1987 1988 1989 <br /> r <br /> 1 f <br /> v <br /> E TANK FEE - 150,00 each TANK <br /> F 1 Tanks 1 150.00 1986 1987 1988 1909 <br /> A (multiply-1-by fee for <br /> C each year applicable) f <br /> I <br /> STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 1 SAFETY CODE Sec 25287 for applicability) <br /> T 1 Tanks 1 156.00 1986 1981 1988 1989 <br /> Y (enter iliount and year) <br /> f <br /> C PERMANENT CLOSURE (Removal or Closure-in-place) <br /> L <br /> D CLOSURE FEE = 190.00 each TANK 1 Tanks___I_ x 190.00 4 90.00 <br /> -- <br /> ___ RICH- MART 10880 <br /> JIM THORPE, DISTRIBUTOR OF QUALITY PRODUCTS <br /> 368-6175 462-4581 <br /> -- - <br /> T 351 NO. BECKMAN ROAD, P.O. BOX 357 <br /> _ -- - -- - LODI, CA 95241-0357 9fY103/1211 <br /> PAY <br /> ,O,« TOTHE <br /> ORDER 0 <br /> OISCOUNT —. '_. CCC��I <br /> AMOVNT Or cHe<K • <br /> DOLLARS <br /> LODI OFFICE <br /> 90 W.Walnut SI.,Lodi,G"2V / <br /> TOTAL DUE 1 <br /> OFFICE USE 011r <br /> z-l :: <br /> LOC CODE DIST CODE AMOUNI DUE AMOUHI RCVD CHECK 1/CASH RCVD BY DATE RECEIVED PERMIT 1 <br /> s ��� . <br /> �2.e— <br />