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OFEE, WORK•SKEET PER EACH FACILITti <br /> �. ' FACILITY .� <br /> DBA / ADDRESS ' <br /> F <br /> MAILING '.11DDRESS s " <br /> 1. .1 Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> dQ <br /> b. Additional Tanks (d� Additional Tanks x $50) <br /> � <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or` ameridment'of operation permit and temporary closure) <br /> SSfi x Total # 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 /> �N Temporary closures x $80) (See above f3 tq. calculate surcharge) <br /> 4e *Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where the owner/operator has no intent � <br /> of reusing tank . <br /> Permanent Closures x $90) <br /> d <br /> 5. Plan Check Fee $30. <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 /> 21 <br /> G7 d ( 90-4412111 <br /> ROBERT H. LEE & ASSOCIATES, INC. 0905 <br /> 900 LARKSPUR LANDING CIRCLE,SWTF 125 <br /> LARKSPUR,CA 94939 <br /> 84151 464-8890 <br /> DOLLARS $-4�—y' <br /> PA Y—�—"- OLLARS <br /> TO CI L <br /> THE ORDER <br /> or <br /> LARKSPUR-KENTFIELD OFFICE D�2 <br /> WEEM ( 1777 MAGNOLIA AVENUE <br /> LAfRKSPUP.,CA 44939 <br /> u■00090 SiI` is L 2 L L L.0 2 1131: 0 5D 7 30 17 S 21I` <br />