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WORxSKET PER EACII FACILITY '��,,� # C? <br /> FACIL I TY <br /> A f i� z)V,1T:F2/A S ADDRESS�a / �� �a/�iN n/1� � ,---s 7'ocT"o,i/ - <br /> LING ADDRESS F ,Qscld �tilAn! yG� (�//�h1�4 CCK ��1�lr�C,4 <br /> Operating Permit Application/Annual Inspection .Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (I Additional Tanks x $50) _ <br /> State Surcharge (per tank) (Due with Permit Application. <br /> on renewal or amendment of operation permit and temporary closure) <br /> (156 x Total I Tanks) <br /> "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 /> 0 Temporaey closures x $80) (See above /3 to calculate surcharge) <br /> "Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where the owner/operator has no intent <br /> o6 re-using tank , <br /> ( fx Permanent Closures x $90) 06 <br /> Plan Check Fee $30. <br /> Total Number of Tanks � '�/OhTot$T, Fee Due <br /> Ike all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> ith your check - <br /> 135-- <br /> L <br /> � �,. .' �� <br /> ^ � NAME �- <br /> 'osr Office 80: NOVEMBER 17 88 <br /> EXAMPLE - ACCOUNT NO.S <br /> _ t t 90-3907/1211 <br /> s ode of SAN JOAQUIN LOCAL COUNTY HEALTH $ 90.00 <br /> NINETY 00/100 <br /> 01? <br /> Valley Commercial Bank <br /> P.O.Box 9700 <br /> c' 1031 East Waterloo Road - <br /> Stockton,califoroia 95208 '. <br /> z - PERMIT JOWt1028 <br /> "i <br /> .000 1--�o xoB-t611� , <br /> Both 11 be conditi d, Contact a Ilealtn District R resenuitir� <br />