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FACILITY <br /> DBA /Lffjicf< f' �i>ff/�r�ia, i'E 4,0 ADDRESS ��� 7G/ • <br /> MAILING ADDRESS l ' ?,3b <br /> Apr tle" �9rS <br /> 1. Operating Permit Application/Annual Inspectior Fee <br /> w. <br /> a. First Tank at Facility @ $150. /SU <br /> b. Additional Tanks (M Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> (156 x Total H Tanks) <br /> 3. *Temporary Closure (per tank) Underground Storage Tank in which <br /> storage has ceased but where the owner/operator proposes to <br /> re-use tank within 2 years. <br /> (A_ Temporary closures x $80) (See above /3 to calculate surcharge) <br /> 4• *Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where the owner/operator has no intent <br /> of re-using tank . <br /> (a_ Permanent Closures x 190) <br /> 5. Plan Check Fee 130. <br /> Total Number of Tanks Total Fee Due A;6 <br /> 0/67 <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with vnnr rhark <br /> _ -- COUNTY OF SAN JOAQUIN _ j <br /> \TOCRTOM, CAL IE 011N 11 <br /> MANTECA-LATHROP RURAL FIRE <br /> E D SPECIAL 133112 01 I **�**J I MAR 31 19 102324 <br /> NNO NO NVYBEN DATE OF ISSUE WARNANr NO <br /> 3J <br /> rws WABPANrsSIX1210 I <br /> Norlr«5 ENON DATE <br /> O or IssUr <br /> suu a C.ew.0 PAY THIS AMOUNT <br /> WILL PAY TO. E. <br /> OR ORDER OF $*****1SO.00* <br /> S J CO LOCAL HEALTH <br /> `Doth <br /> <br /> 2-A6 <br /> I <br /> UGT a I • • <br />