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DBA tALILIIY <br /> ADDRESS ) > P 12n S 1ZJC <br /> MAILING ADDRESS <br /> 1. Operating Permit Applicatiul /Annual Inspection Fee <br /> a. First Tank at Facility @ $150. iQgt>g TSV <br /> b. Additional Tanks (0t Additional Tanks x 850) <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 N r 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 /> (M_ Temporary closures x 880) (See above N3 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 • PAYMENT <br /> (N [ Permanent Closures x 890) RECEIVgp qC) <br /> 5. Plan Check Fee $30. Q[, [ • 19 �_ <br /> �rvlao+va�€�u HERE <br /> PEknn�a��y10E$� <br /> C5 c. <br /> Total Number of Tanks Total Fee Due �ij` <br /> Make all fees payable to San Joaquin Local Health District Enclose this worksheet <br /> with your check <br /> E. R. ENGDAHL <br /> 7 W. CANTERBURY DR. 231 .5 <br /> STOCKTON, CA 95207 ��p` <br /> 19�4 11-24 <br /> T Q 1210(8) <br /> T <br /> PAY TO THE �', <br /> ORDER OF <br /> --BBL{AR3 <br /> SiOCKiON MAIN OFFICE <br /> WELLS FARGO BANK <br /> 003 N.EL OORAW S .SIOCKtt ,CA 95202 <br /> FOR <br /> `Both closures will be conditioned. Contact a Health District Representative. <br /> 2-86 <br /> UST �� <br />