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tLL WORKSHLLl PER EACH FACILITY <br /> FACILITY �QvVT 5 <br /> DBA /yJ 4G �Z AD <br /> oRESS : U <br /> -, - <br /> MAILING ADDRESS <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (I AdditionalTanksx, $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application* <br /> on renewal or amendment of operation permit and. temporary closure <br /> I <br /> (S56 x Total I Tanks) � r+�� <br /> 3• "Temporary Closure (per tank) Underground Storage Tank in which Nod 1 <br /> storage has ceased but where the owner/operator proposes to <br /> re-use tank within,2 years. PERMIT I510V'(,W <br /> (I_ Temporary closures x $80) (See above 03 to Ir calculate surcharge) <br /> 4- "Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where ;the 9wner/operator has no intent <br /> of re-using tank, o 6 <br /> (f_ Permanent Closures x $90) k Z <br /> 5. Plan Check Fee $30. <br /> Total Number of Tanks Total Fee Due Ile 0 0 <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> p1�M[~M�OwwO..� <br /> RICH-MART 10 2 0 5 <br /> JIM THORPE, DISTRIBUTOR OF QUALITY PRODUCTS <br /> 388-8175 482-4581 <br /> r <br /> i351 NO. BECKMAN ROAD. P.O. BOX S57 <br /> CA <br /> LODI <br /> �. . 85241-0357 <br /> 1 <br /> PAY <br /> TO THE <br /> t m <br /> ORDER lF $�j <br /> O�DOLLARS <br />