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FEE WORK•SHL-�l KR CACH FACILITY <br /> FACILITY I �r C� U� . U�vl>W1 PyelblenA) <br /> 08A . U'�1�� I'��,. ADDRESS <br /> MAILING ADDRESS <br /> 1. Operating Permit Application/Annual Inspection Pee <br /> a. First Tank at Facility @ $150. -- <br /> b. Additional Tanks (1' Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Dine with Permit Application, <br /> on renewal or amendment of operation permit and. temporary closure) <br /> ($56 x Total 1 =' 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 2Y ears. <br /> {!` Temporary closures x $60) (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 r <br /> of re-=using tank', S3:XM3S1t1M3d <br /> (11 Permanent Closures x $90) ,Tq1'1b3H Id1N3WNICIVANI J �� <br /> 5. Plan Check Fee $30. <br /> �3►N IN <br /> Total Humber of Tanks -�al Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. <br /> SEMCO151 <br /> u, <br /> TERRY HAMILTON, PRESIDENT 3 <br /> RICHARD C. HAMILTON, V.P. <br /> PH. 209-524-9653 i' <br /> 431 W. HATCH ROAD Jq— <br /> M DESTO, CA 95951 <br /> PAY TD THF --- — V <br /> ORDER OF QL <br /> oa <br /> DOLLARSS � <br /> UNION SAFE ph <br /> DEPOSIT <br /> BANK <br /> }'46M®yf(/�/a'dway,SH11dda,CCCA 9/533668(� <br /> 1"1 + <br /> *Bot <br /> E <br /> . -s— - � _ eamxRa/L'_�a-451fleniMlle�+J <br /> r,�rl 23 032 2/86 <br />