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NM <br />MAILING ADDRESS_ <br />02324 <br />NUMBER OAK M ISSUE <br />WA... WI NO <br />11-35 <br />'MIS WARRANI VOID SIII <br />I. <br />Operating Permit Application/Annual Inspection Fee <br />a. First Tank at Facility @ $150. <br />b. Additional Tanks (N Additional Tanks x $50) <br />2. <br />State Surcharge (per tank) (Due with Permit Application, <br />on renewal or amendment of operation permit and temporary closure) <br />(156 x Total N Tanks) <br />3. <br />*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 />(N _ Temporary closures x 180) (See above 13 to calculate surcharge) <br />4• <br />*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 />(q_ Permanent Closures x $90) <br />5. <br />Plan Check Fee $30. <br />Total Number of Tanks <br />Total Fee Due <br />Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br />with vnllr rhArk <br />COUNTY OF SAN <br />&TOORTOM. CAU{ORMIA <br />MANTECA-LATHROP RURAL FIRE <br />E <br />V SPECIRL 33112 01 <br />1UNO NO <br />"Both <br />2-86 <br />Tn. 1--, .1 1— I.,R, „ Gown <br />WILL PAY TO. <br />OR ORDER OF <br />*******I MAR 31 IW <br />02324 <br />NUMBER OAK M ISSUE <br />WA... WI NO <br />11-35 <br />'MIS WARRANI VOID SIII <br />1210 <br />MOMTNS FROM OA'E Of ISSUF <br />PAY THIS AMOUNT <br />S J CO LOCAL HEALTH <br />()( X! <br /> <br />I <br />