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FEE WORKSHEET FOR EACH FACILITY <br /> DBA FACILITY ADDRESS A� q6k �nl(j <br /> MAILING ADDRESS <br /> 1 . Operating Permit Application/Annual Inspection Fee <br /> a. First 'Tank at Facility @ $150 . _ <br /> b. Additional Tanks ( # Additional Tanks x $50 ) y <br /> 2 . State Surcharge (per tank) ( Due with Permit Application <br /> on renewal or amendment of operation permit and temporary <br /> closure. ) <br /> $56 x Total # Tanks ) <br /> 3 . *Temporary Closure (per tank) Underground Storage Tank in <br /> which storage has ceased but where the owner/operator pro- <br /> poses to re-use tank within two ( 2 ) years . <br /> # Temporary closures x $80 . (See above #3 to calcu- <br /> late surcharge) <br /> 4 . *Permanent Closure (per tank) Underground Storage Tank in <br /> which storage has ceased and where the owner/operator has <br /> no intent of re-using tank. PAYMENT <br /> # - Permanent Closures x $90 <br /> RECEIVED <br /> 5 . Plan Check Fee: $30 . 00 <br /> DEC 1 1988 <br /> TOTAL NUMBER OF TANKS - NViRONMENTAZ MDV)g- FEE DUE <br /> PERMIT/SERVICES <br /> Make all fees payable to: San Joaquin Local Health District <br /> Enclose this worksheet with your check. <br /> - -- -- ---------------- <br /> Bank of America 11.35 002657 <br /> Madero Bionth 0023 1210 <br /> P.O. Box 209 Madera, CA 93639 <br /> T -� �' �Yttyn�yltp �Vl�$, Ll�r CHECK DATE CONTROL NO. �{AMOUNT <br /> i7 +GEL�N+EiRA1L1,FUNND ACCOUNT 1 �— 173&- <br /> 11855 ROAD 29 <br /> MADERA,CA 93637 <br /> 673-2228 <br /> PAY V. _ � 1Jfi �- <br /> TO THE <br /> ORDER H. YDNDIIN & 8©N8, LTD. <br /> OF tG GENERAL FUND ACCOUN i <br /> a,\� , <br /> 8 <br /> Ell 23 032 2/86 <br />