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rtt wuttKJHttI PER tACH hAClL1iY <br /> .. FACILITY <br /> DBA ' fJ( prw•y ADDRESS — —T <br /> NAILING°`AOORESS S! - <br /> 3 <br /> 1 Operating Permit Application/Annual Inspection Fee SbO7 Sb 0 <br /> a., first Tank at Facility @ $150. <br /> b. Additional Tanks (/ 2� Additional Tanks x $50) JUC� lobo <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total lam_ 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 /> (#_ Temporary closures x $80) (See above 03 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 /> ;CO <br /> (l '? Permanent Closures x $90) <br /> 5. Plan Check Fee $30. <br /> Total Number of Tanks 3 Total Fee Due �•���� <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check, <br /> L O D I ACADEMY FARMERS A MERCHANTS BANK 90 844 <br /> OF CENTRAL CALIFORNIA DATE CHECK NO 21 i <br /> LA 1230 S. CENTRAL AVE. LODI CALIFORNIA <br /> - \,• LOW. CA. 95240 June 16 , 1988 <br /> CONTROL NO. 13272 <br /> I y CHECK AMOUN* <br /> ACAOEMT7- .� CJ G.PI I, <br /> PAY DOLLARS AND CENTS <br /> TO THE ORDER OF <br /> San Joaquin County - Health Department LODI ACADEMY <br /> Y <br />