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OBA ADDRESS I/ y' �7 U•u <br /> MAILING ADDRESS NVj <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (/ 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 /> (I_ Temporary closures x $80) (See above /3 to calculate surcharge) <br /> G. "'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 /> (/_ Permanent Closures x $90) <br /> 5. Plan Check Fee S30. <br /> Total Number of Tanks Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check - <br /> j RICH- MART <br /> P - JIM THORPE, DISTRIBUTOR OF QUALITY PRODUCTS 10176 <br /> 368-6175 4624581 <br /> 351 NO. BECKMAN ROAD <br /> , - P.O. BOX 357 <br /> LODI. CA 95241-0357 <br /> v <br /> PAY /G 19�✓ <br /> TO THE <br /> ORDER OF <br /> �Oo DOLLARS <br /> lI <br /> IO <br /> - - 9 <br /> �b W.W "'S'OFF f <br /> C,U951q <br /> _ -- - <br /> UGT -V <br />