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FEE WORKSIiEET •PER�EACH FACILITY 9 r� <br /> DBA a /�j C �ic ADDRESSY <br /> MAILING ADDRESS SIA <br /> 'a <br /> 1. Operating'Permit `Appiication/Annual= inspection'fee <br /> a. First Tank at Facility @ '$150, <br /> b. Additional Tanks (l Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, 0164, <br /> on renewal or amendment of operation permit and temporary closure) , <br /> ($56 x Total N 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 /> (I_ Temporary closures x $80) (See above /3 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, boa <br /> (I I Permanent Closures x $90) <br /> 5. Plan Check Fee $30. <br /> Ck 166 3 2, <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 /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> ( 1 rPnular 1 union AnA L c..nrmm� 1 ...nc fn nill - <br /> f <`� RICH - MART 10032 <br /> JIM THORPE, DISTRIBUTOR OF QUALITY PRODUCTS <br /> 368-6175 462-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 90-103 <br /> li <br /> LODI, CA 95241-0357 �_ `� , 1 } r� 1211 <br /> /- <br /> -- 11 PAY <br /> p-------- TO THE <br /> L I osco�� ilORDER OF -'C, (f� <br /> DOLLARS <br /> "ec BANK OF STOCKTON _ <br /> LODI OFFICE <br /> 120 W.Walnul 5t.,Lodi, <br /> CA 95240 <br />