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ILL WVMrOILLI VIE tALN FACILIIT <br /> � l � FACILITY I� <br /> OBA �, <br /> ADDRESS <� ( � <br /> MAILING ADDRESS <br /> I. Operating Permit Application/Annual inspection Fee <br /> a. First Tank At Facility @ $150. <br /> b. Additional Tanks (N 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 /> ((_ 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 _ PAYMENT <br /> (l� Permanent Closures x $90) RECEIVED I <br /> 5. Plan Check Fee 530. JUN I Iood <br /> ENVIRONMENTAL HEALTH <br /> PERMITISERVICES I <br /> Total Number of Tanks r:;)-- 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 /> RICH - MART <br /> 10058 <br /> - JIM THORPE, DISTRIBUTOR OF DUALITY PRODUCTS ' <br /> - _ 368-6175 462-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 <br /> LODI, CA 95241-0357 / ^}/19 a �/1 <br /> <br /> PAT J ^ �/� O <br /> RDER Q <br /> . OOF <br /> ..,o,.N.OF �^ L >�/ � �`. C9 DOLLARS <br /> BANK of STO ON <br /> LODI OFFICE � z <br /> 120 W.Walnut St.,Lodi,CA 95240 <br /> -__J <br />