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FEE WORKSHEET PER EACH FACILITI <br /> FACILITY <br /> OBA ADDRESS <br /> MAILING ADDRESS C-1/4 <br /> 7� 7j <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ 1150. <br /> b. Additional Tanks (I 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 /> (S56 x Total N 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 /> (f_ Temporary closures x $80) (See above I3 to calculate surcharge) <br /> 4• "Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where the gwner/operator has no intent <br /> of re-using tank , <br /> (N Permanent Closures x $90) <br /> 5. Plan Check Fee $30. <br /> Total Number of Tanks 7 Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check, <br /> ,M ACCOYM[ <br /> RICH - MART 10171 <br /> JIM THORPE, DISTRIBUTOR OF QUALITY PRODUCTS <br /> 368-6175 462-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 <br /> LODI. CA 95241-0357 �j / -- - <br /> PAY - -- .. <br /> TO TH E <br /> roma. <br /> ORDER OF <br /> AMOUNT DI CD[CD 4 .��,60LLARS <br /> Bar fSroc on <br /> loDI OFFICE <br /> 40 W.W aInm 9.,Lodi,CA 952W / <br /> — <br /> L <br /> 2 <br /> lAC!T 7 1 <br />