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LOOPI <br /> FAC!C I TY <br /> MAILING AOORI ADDRESS C <br /> V <br /> �Perating. Permit Application <br /> lAnnaalInspection Fee <br /> a. First Tank . <br /> at 'FdCilitY @,>S <br /> ISO <br /> • <br /> b• Additional Tanks (/ <br /> _� Additional Tanks <br /> 2• State Surcharge (per tank x 350) <br /> ) (Due with Pe •~-'----"' <br /> on renewal or amend Permit Application. <br /> meat of operation ��- <br /> (�.56 x Total y permit and temporary closure) <br /> Tanks) <br /> 3• 'Temporary Closure - <br /> (per tank) Underground Storage Tank in which <br /> storage has ceased but where the �~~ <br /> owner/operator proposes to <br /> re-use tank within 2 years. <br /> (1. Temporary closures x $go) (See above 13 to cal <br /> 4, 'Pernianent Closure (per tank) Undergroundculate surcharge) <br /> Storage Tank in which <br /> storage has ceased and where the owner/operator has no intent <br /> of re-using tank , <br /> (i l Permanent Closures x $90) PAYMENT <br /> ^ <br /> 5. Plan Cheek Fee S0. RECEIVED 9n <br /> MAY 31 �9 <br /> .ENVIRONMENTAL HEALTH <br /> Total Number of Tanks PERMIT/SERVICES <br /> Total Fee Due <br /> Make all fees payele to San Joaquin Local Health District. Enclose this worksheet <br /> with your Check , <br /> E. <br /> SEMCO = c <br /> TERRY HAMILTON PRESIDENT 1238 <br /> RICHARD C. HAMfLTON, V.P. <br /> PH. 209-524-9653 I <br /> 431 W. HATCH ROAD <br /> MO STO, CA 95351 —1� <br /> Inv ro THE }� <br /> ORDER OF_`.- - - � <br /> � --- DOLLARS � . <br /> ENTER STATE BAN <br /> 4600 EiROADWgy <br /> SALID CALIFORMfq 95368 ' <br /> *Both <br /> 2-?1G <br />