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I L" L14.11 1 ALILI i <br />DBA 5 ��9 U�i� S� SLi?S s. ADDRESS 1;2791 ;5- <br />MAILING ADDRESS <br />I. Operating Permit Application/Annual Inspection Fee <br />a. First Tank at Facility @ $150. <br />— <br />b. Additional Tanks (R Additional Tanks x 450) <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 R Tanks) <br />_ <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 />(R _ Temporary closures x $80) (See above R3 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 />(R__c7- Permanent Closures x $90) <br />S. Plan Check Fee $30. <br />Total Number of Tanks Total Fee Due <br />/ �U <br />Make all fees payable to San Joaquin Local Health District Enclose this worksheet <br />with your check <br />1\\\ r <br />CASJERZ <br />ASE�-l!� <br />2.00 <br />BANK of STOCKTON No. 024502 <br />MANTECA OFFICE <br />206 E Yosemite Ave., Mameca, CA 9533690-103u�� 1 1 <br />'��V' • 988 <br />DATE <br />PAY TO THE @ ,��� <br />ORDIiR OF **San Joaquin Local <br />$** Health District** ## <br />B 1-11 �.r I .t 1• 1 I�� 1,N,� 44 �'�� <br />1 11 V»"1 1. a mvlw DOLLARS <br />CASHIER'S CHECK <br />L <br />T AV ORI SIG NhTV RE <br />