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FEE WORKSHEET PER EACH FAC1,, Y <br /> /�- FACILITY /� /}� <br /> DBA n 1 E, I (_11VN Y1La 111 n iA v , ADgD'RESS S l dQ �L 1 S (wJ 64 LOAD ��Gto r <br /> t(AILING ADDRESS PL AW 'q�(pfrj VlLAhF�� � S��y <br /> I. Operating Permit Application/Annual inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (N 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 /> ($56 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 /> (Y_ Temporary closures x $80) (See above N3 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 /> (/'—L Permanent Closures x $90) PAYMENT <br /> _L <br /> 5. Plan Check Fee 530. RECEIVED <br /> JUN -. 19b_: <br /> 5NVIRONMENTAL HEALTH <br /> Total Number of Tanks PEPWIT/SER\/fdal Fee Due RQ � <br /> i <br /> Make all fees payable to San Joaquin Local Health District Enclose this worksheet <br /> / CRISP CONSTRUCTION CO., INC. t <br /> WARREN JONES Y 138 <br /> FIELD ACCOUNT <br /> P.O. BOX 1066 209.734-6381 <br /> VISALIA,CA 93279 <br /> $ <br /> First f� of C dlf ,&a Bank <br /> d <br /> of t IAn <br /> A t <br /> Interstate v"iaotf" <br /> Bank 414 West MW SbMt <br /> VWiq CA 93241 <br /> 'Both closures Hill be conditioned. Contact a Health District Re resentative. <br /> 2-::L <br />