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FEE WORK-SHEET PER EACH FAClLIT` <br /> D8A �hcl� N i�tiv FACILITY -7--7p / 7^� <br /> Q `/SjD.`Sf ADDRESS GLJ• � <br /> MAILING ADDRESS -7-7 D 0- a.,I Z61iil ' If 4 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (/ 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 /> ($56 x Total 1 Tanks) PAYMENT <br /> 3. "'Temporary Closure (per tank) Underground Storage Tank in which RECEI VEP <br /> storage has ceased but where the owner/operator proposes to SEP 2 3 <br /> Lydd <br /> re-use tank within 2 years. <br /> (/_ Temporary closures x $80) (See above /3 to calculate surchargRQ NMENTAL H;qy" — <br /> 4• "Permanent Closure (per tank) Underground Storage Tank in which <br /> ftMIT�SERVICES <br /> storage has ceased and where the owner/operator has no intent <br /> of re-using tank, �� <br /> (I� Permanent Closures x $90) <br /> 5. Plan Check Fee S30, <br /> Total Number of Tanks Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this /worksheet <br /> �--A <br /> with your check. * /0/h3 <br /> eC "OLL-E` p"""E 7 RICH - MART 1016 3 <br /> �T <br /> o~ titl V JIM THOflPE, DISTRIBUTOR OF QUALITY PRODUCTS <br /> 368-6175 462-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 90-103/1211 <br /> LODI, CA 95241-03579 <br /> PAYTHE J� �.F' I( (/�/ �0�t. <br /> • .ornI ORDER OFFFF�°°°��� —(I —S g � �/ <br /> " nrnauHtavCHEC,c .,, O/ _ ��n//�? DOLLARS <br /> Bank <br /> IOEIIOFFICE <br /> IN W.walnut St.,Lodi,CA 952Q <br /> •e0 <br /> 11201016311' 1: 1211010371: 23FF10019 7611, <br />