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FEE WORKSHLET PER EACH FACILITY <br /> OBA GlJ•% bI c(a�tto(/ � (G> FACILITY <br /> ADDRESS <br /> MAILING ADDRESS 5 1A <br /> I. Operating Permit Application/Annual Inspection Feer; <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (A Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> MIS 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 /> (d_ 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 intentI <br /> of re-using tank . <br /> cc <br /> (#_-� Permanent Closures x E90) a �? D <br /> S. Plan Check Fee $30. i A )� � <br /> ENVIROMENTAL HEALTH <br /> FERMIT/SERVICES <br /> Total Number of Tanks °J <br /> Total Fee Due 2 � � <br /> Make all fees payable to San Joaquin Local Health District Enclose this worksheet <br /> with your check . <br /> EXPLANATION <br /> <br /> 1845 FULKERTH RD. ^ ^ <br /> TURLOCK.CA 95380 `, L <br /> (209)668-8441 <br /> PAY <br /> AMOUNT <br /> OF aiLfdF' `lY 20,_ <br /> --QQLj-..RS CHECK <br /> GATE TO THE ORDER OF ACCTS.PAYABLE DISC. OTHER CHECK AMOUNT <br /> NUMBER <br /> II <br /> $[ <br /> CHECK VOID IF NOT CASHED WITHIN 30 DAYS <br /> GUARANTEE SAVINGS <br /> 2000 GEER RD. TURLOCK.CA 95380 <br /> Qn-r I <br />