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FEE WORK-SHEET PER EACH FACILITY , <br /> FACILITY <br /> DBA &_ .e,,✓rc, K ADDRESS <br /> MAILING ADDRESS S <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. l'G <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 /> 456 x Total k 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 /> (1_ Temporary closures x $80) (See above /3 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 /> U t Permanent Closures x $90) <br /> 5. Plan Check Fee $30. <br /> rr <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 /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> RICH - MART 10169 <br /> JIM THORPE, DISTRIBUTOR OF DUALITY PRODUCTS <br /> 368-6175 462-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 G 90,103/1211 <br /> LODI, CA 95241-0357O <br /> /�— <br /> _19 <br /> PAY <br /> TOTHE E $ � <br /> +orn� ORDER OF <br /> t <br /> wecoun* . �,.CJ <br /> K c_ - --- -.e!;l -010-DOLLARS <br /> Bank.° tOC�Oft <br /> LOD OFFICE <br /> 40 W.Walnut H.,Lodi,CA 9S2W A <br /> 11.01016911' I: 12*710i0371: 2 97611.O1r— <br />