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FEE WORK-S HCET PER EACH FACILIT• FACILITY a a y •� S C--wti✓u�t / � � <br /> DBA <br /> MAILING ADDRESS as �f�� C S�4�iu�t� 0 ' <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (I Additional Tanks x $50) <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 M Tanks) <br /> 3. "Temporary Closure (per tank) Underground Storage Tank in which PAYMENT <br /> storage has ceased but where the owner/operator proposes to RECEIVED <br /> re-use tank within 2 years. SEP 2 3 IHS <br /> (/_ Temporary closures x $80) (See above /3 to calculate surcharge) <br /> ENVIRONMENTAL HEALTH <br /> 4. *Permanent Closure (per tank) Underground Storage Tank in which PERMIT/SERVICES <br /> storage has ceased and where the owner/operator has no intent <br /> of re-using tank 41� <br /> (1'/ Permanent Closures x $90) ff' <br /> 5. Plan Check Fee $30. <br /> Total Number of Tanks Total Fee Due 9 ` o <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check, <br /> �4 oN' N7 (J�._ RICH - MART <br /> JIM THORPE. DISTRIBUTOR OF QUALITY PRODUCTS 10163 <br /> 368-6175 462-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 <br /> LODI, CA 95241-0357 q (/(/ 90 V1211 <br /> PAY / _19_t�0 <br /> TOTAL TO 7HE dpi <br /> ORDER OFF°° _-X21-- J $ <br /> - oiacoorvr —1 - <br /> INT.1 OMECK <br /> Bank, <br /> A4'_ (Y at-`L '-I' v <-�1Z DOLLARS <br /> On - / <br /> LODE OFFICE <br /> 'a W.W"nuL St.,Lodi,CA 9520 (I 1-71r <br /> 7111'�VJ�✓Q�� <br />