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SAN OAQU I N LOCAL HEALTH D 4R I CT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F FACILITY/SITE NAME FACILITY CONTACT NAME <br /> a <br /> L STREET ADDRESS (� SITEIHONE�_"ITN AREA COD[ <br /> Y CITYTAT IP�CODE 1 of Tanks <br /> STAT je)cl at Site <br /> A APPLICANT/BILLING NAME APPLICANT CONTACT NAME <br /> P ,- <br /> Tvc:�tC�z��/\ L�+�I'v�cam'��-L7'�-t t�✓\ �`-�• 1 ���-_ L� 1�L_S __.. <br /> I MAI NG ADDRESSPPl CAN PHONE 1 .1TN AREA CODE <br /> 71 <br /> N CITY STAT IIP CODE TYPE of APPLICATION <br /> T ! /req � ` CLOSURE, INETALLAT ION, [TC. <br /> FACILITY FEE : 1100.00 each SITE ADDRESS per YEAR TOTAL <br /> A _ __-- --- -_..._.._...__...__----- - .._._............-.--------- <br /> T - 1386 - 1981 - 1988 _ --1989 — _- -- ---------- <br /> �I -.......---._.-._-.. - - -- --- ------ <br /> E TANK FEE = 150.00 each TANK <br /> F 1 Tanksr 150.00 1986 1987 1988 1989 <br /> A (multiply_1 by lee for _..-_... ..- _.-- ------- -- -- -----.. <br /> C each year applicable) <br /> L STATE SURCHARGE = 156.00 each TANK (see CA HEALTH 11 SAFETY CODE Sec 25281 for applicability) <br /> T 1 Tanks x 156.00 1986 1981 1988 1983 <br /> Y (enter Night and year) <br /> f71 JBANK OF STOCKTON 90-103 <br /> oo�wG <br /> COMMERCIAL SAVINGS TRUST .-_-_.-_-•___.-.- <br /> STOCKTON.CALIFORNIA 1 21 1 <br /> w I I <br /> CALIFOW820 RNIA CONTRACTOR LICKTON,VCCALIF. 9 C-61,SA 26657 <br /> �- <br /> 908-820 N.LIMON 9T.,STOCKTON, AT P. 95209 -- _ <br /> P.O. BOX 909 STOCKTON,CALIF. 93201-0908 <br /> PHONE 209/46.-9979 _----- -__ <br />'JAY V- fl704 1 k1tJ DOLLARS ---- -- -- <br /> DATE CHECK NO. • IIIIIJ <br /> D <br /> ��.OLLARS ICENTS <br /> -•---___---__._._.._____. <br /> TO 7HE ,C/ � ` C 3 O <br /> RDER OF v � 1 �J �V 1 <br /> STOCKTON SERVICE STATION EQUIP.CO.,INC. 1 <br /> 1...1......_...__..._._..._...._..........._,.........._.._................ <br /> -----_ ___..._..--------------•------------ - TOTAL DUE .`._. ..__-;Jn----------- <br /> OFi1Cf USE ONLY <br /> 11 ffimi.m. WPM awl <br /> SWEEPS 1 COMP 1 LOC COOS DIST CODE;AMOUNT DUE AMOUNT RCVD CHECK 1/CASH RCVD DY DATE RECEIVED PERMIT�� . (� 1� WWI WIN <br /> .I. <br /> �' U a <br />