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FEE WORKSHEET PER EACH FACILITTw <br /> FAC •I . <br /> DBAADDRESS <br /> MAILING ADDRESS . + <br /> 1. Operating Permit Application/Annual Insped, o;';:fee; <br /> y <br /> a. First Tank at Facilitv P SISO. 171 <br /> b. Additional Tanks (/ Additional Tanks x $50) 4 + ;r"• <br /> 2. State Surcharqe (per tank) (Due with Permit Application, .,. <br /> on renewal or amendment of operation permit and temporary closure) <br /> (S66 x Total M 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 /> 0_ Temporary closures x $80) (See above f3 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 - A 7 O <br /> (9 J Permanent Closures x $90) PAYMENT <br /> S. Plan Check Fee S30. RECEIVED <br /> MAY 3 1 iyr�,7 o?70 <br /> ENVI10NMENTALTbEA1Thee Due <br /> Total Number of Tanks PERMIT/SERVICES <br /> T <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check . <br /> SEMCO <br /> TERRY HAMILTON, PRESIDENT 1238 <br /> RICHARD C. HAMILTON, V.P. <br /> PH. HATCH ROAD <br /> EXAMPLE - Annual 437 H. HATCH ROAD <br /> MO STO, CA --.-19 <br /> ( 1 rel PAY FO TMF 953.51 <br /> ORDER OF. <br /> DOLLARS <br /> TERSTATE BqN2- 4600 BROADWAY <br /> SALID , CALIFORNIA 9g385 <br /> Tota' MfMOzz <br /> *Both closures will be conditioned. Contact a Health District" Representarivr_ ;-- - <br /> 2-86 <br />