Laserfiche WebLink
SAIVJOAQUIN LOCAL HEALTHWSTRICT <br /> UNDERGROUND STORAGE TANK PROGRAM - FEE WORKSHEET <br /> F� FACILITY/SITE NAME A�__ FACILITY CONTACT NAME C vl2j L,s►.,, — <br /> C or <br /> L ITREENDiDRESS SITE , ONE I WITH AREA coos <br /> T ._ -; <br /> Y CITY STATE .IIP CODE I of Tanks <br /> at Site <br /> A APPLICANT/BILLING NAME <br /> P APPLICANT CONTACT NAME <br /> I MAIL{I�NG,A�DDRESS APPLICANT PHONE I WITH A A con <br /> NCITY TATE IiP'CODE A IC <br /> c6oauR , H `Acro ETC. <br /> FACILITY FEE = $100.00 each SITE ADDRESS per YEAR <br /> A ..... __.._.._.. .. _. _ _ TOTAL <br /> C 1986 _ 1987_.... ..._1988_.._.. ._._......._._ ..,,_....,._....._.. <br /> T 1989 <br /> I <br /> E TANK FEE = $50.00 each TANK <br /> F I Tanks ..._x $50.00 1986 � 1981 1988 1989 _ <br /> A (eultipfy" t"by fee for <br /> I each year applicable) $ <br /> -M._...__._e ® - �d <br /> L STATE SURCHARGE = $56.00 each TANK (see CA HEALTH L SAFETY CODE Sec 25281 for applicability) <br /> I <br /> T 1 Tanks__l x $56.Oti 1986 1981 1988 1989 <br /> Y (enter aJount and year) <br /> I; pi P.O.BOX 99 BILL GARD <br /> ( ....., Antioch,CA 94509 <br /> 0 CL (415)754-4334 President <br /> S I Tanks__ _ x $90.00 <br /> U _ <br /> TEDELTA/BAY BUILDERS, INC. <br /> TE LONE TREE WAY,ANTIOCH AIRPORT ^•�^----- <br /> I Tanks _—— x $80.00 _ $ <br /> P Pt •Service Stations • Fuel Systems µ <br /> L •Tank Installations •Mini Markets <br /> A <br /> NPL....--_..._.. ..- __... ._... �__..._. $ <br /> R DELTA/SAY BUILDERS <br /> E ' P.O. BOX 99 415-754-4334 <br /> 107 <br /> P ' <br /> A ANTIOCH, CA 94509 <br /> R PAY 90-4129/1211 <br /> TO THEt ,r-<7 <br /> 'F ORDER OF � <br /> Esst County Blank,N.A. DOLLAR S <br /> 315 G Street <br /> Antioch. CA 94509 ` <br /> S FORJar�va.%j <br /> u■000 10 ?n' -11: 1 2 114 1 29 11: 20000 18 1u'' 0 6 ? <br />