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FEE WORKSHEET PER EACH_ fACLL1T1�+er!e <br /> OBA /j h ADDRESS 1 <br /> MAILING AOORESS �� " �• <br /> 1. Operating Permit Application/Annual inspe C, c, e <br /> a. First Tank at facility @ S1511 rr 1 <br /> t. 3 <br /> b. Additional Tanks {/ Additional 7anksx�4507 <br /> 2. State Surcharge (per tank) (Due with Permtt �lppltea ioq., j�uf5 sa <br /> w r amendment of operation permit 'apd temporary dosure)a ��:4"r <br /> on renewal o rt. <br /> (S56 x Total N Tanks) * <br /> r <br /> 3. *Temporary Closure (per tank) Underground Storage T�nk7Tn t+htch, r 1 i <br /> j1 j <br /> storage has ceased but where the owner/operatordgroposesYto r° <br /> re-use tank within 2 years. �a <br /> (1 Temporary closures x $80) (See ,above /3,to caicu ate i►re►1' : F <br /> 4. `Permanent Closure (per tank) Underground StoragezTankat 1 <br /> storage has ceased and where the owner/operator has no' intent 'amu , <br /> r s" p y <br /> of re-using tank . <br /> (AJ Permanent Closures x $90) PAYMENTP'sy ' <br /> 5. Plan Check Fee S30. RECEIVED <br /> M 1. <br /> AY <br /> 1 <br /> y <br /> ^ kNVIRONMENTALT1dtA1A' ee Due <br /> f <br /> Total Number of Tanks v PERMITJSERVICES: t'r <br />! 1 1 h- <br />' Make all fees payable to San Joaquin Local Health District. Enclose this`workshe'et <br /> with your check , <br /> S SEMCO <br /> TERRY HAMILTON, PRESIDENT 1238 <br /> l RICHARD C. HAMILTON, V.P. <br /> PH. 209-524-9553 <br /> EXAMPLE - Annual 431 W. HATCH ROAD y �/ <br /> -- MO STO, CA 95351 19(1 o 99-1314/1211 <br /> ( 1 rel Fnr TO THE $ <br /> ORDER OF - <br /> 1 <br /> } b. DOLLARS <br /> GEIVTER STATE 6Ary <br /> • 2• ' CJ 4800 BROADWAY _ <br /> C] SALID • CALIFORNIA 95388 - <br /> I <br /> Tota' MfMO <br /> 1: 1 211131484 i 2313... 03•• or3744...oils <br /> kr <br /> *Both closures will be conditioned. Contact a Health Di Ste 'CReprese„ta"Mv Vag <br /> i2—}ill I 1. e '•~�t. S`�t "• <br /> F <br />