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FEE WORKSHCET PER EACH FACILI <br /> Sf c�SFo �C//'P FACILITY <br /> DBA _ <br /> _—�� �/ ADDRESS <br /> MAILING ADDRESS---/ J /J/, ��. / 61� rl_1� -I-z5c/s fxh / , Cfq 15 0 <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (f 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 /> (856 x Total f 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 /> (#_ Temporary closures x 880) (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. p <br /> (f/ Permanent Closures x 890) /d <br /> 5. Plan Check Fee 830. <br /> Total Number of Tanks Total Fee Due �G <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. <br /> EXAt -- -- --- -- - <br /> CRISP TANK TESTING 1240 <br /> 2004 PICCOLI RD. 462-5650 <br /> STOCKTON, CA 95205 <br /> TO THE <br /> PAY <br /> ORDER OF $ <br /> i <br /> )LO LL A R S <br /> Valley Commercial Bank <br /> r.u.u�.evuo <br /> 1031 h:xel Wvreduo RaeJ <br /> C Siceklon.Coli or OB /�� �J / <br /> 'Both C FORsL _(�- P _1 <br /> I <br />