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FACILITY <br /> ADDRESS <br /> DBA <br /> MAILING ADDRESS <br /> Operating Permit Application/Annual inspection Fee 967 8? <br /> a. First Tank at Facility @ $15Q. <br /> b. Additional Tanks (/ Additional Tanks x $50) <br /> 2. State Surcharqe (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) 5/ <br /> (S56 x Total N Tanks) �G <br /> 3. 'Temporary Closure (per tank) Underground Storage Tank in which <br /> I storage has ceased but where the owner/operator proposes to <br /> i <br /> re-use tank within 2 years. <br /> (1'_ Temporary closures x SEW (See above l3 to calculate surcharge) <br /> 4 • *Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where thh owner/operator has no intent <br /> of re-using tank , <br /> (N Permanent Closures x $90) PAYMENT <br /> S. Plan Check Fee 530. <br /> RECEIVED <br /> MAY 3 11988 <br /> ' ENVIRgMkNTP4j HEALTH 7� <br /> Total Number of Tanks PERMITJSERVICES <br /> I .s . <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check . <br /> EXAMPLE - Anr <br /> -- 1239SEMCO <br /> ' <br /> ( 1 TERRY HAMILTON. PRESIDENT <br /> RICHARD C. HAMILTON, V.P.PH. s ffff <br /> i <br /> la. I W HATCH ROAD <br /> I 19 9p-1314/1211 <br /> 1 W. HATCH ROAD 47�J/-- B <br /> (9, ODESTO, CA 9535I}y1 $ <br /> 2 Ip) PAY TO THE Ir. � N <br /> ORDER OF— ----- ����l1VV - - -�^' <br /> DOLLARS , <br /> Tol .j <br /> ' CENTSALER STATE BANK <br /> p 4600 BRRRR���ADWAV <br /> O I AyF{JRNIA 95360 TM <br /> MFM 1X/ IX`VA�V�y..,_...VVVfffVVV//VVVTrr1 . <br /> 'Both closures w <br /> 2-N6 <br />