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FEE HORKSHEET PER EACH fACILITO FACILITY • <br /> DBA <br /> MAILING ADDRESS a `' <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a, First Tank at Facility @ $150- <br /> b. Additional Tanks (I Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Applications <br /> on renewal or amendment of operation permit and temporary closure) <br /> (156 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 gwner/operator has no intent <br /> of re-using tank, <br /> (/_�_ Permanent Closures x $90) <br /> 5. Plan Check Fee $30. c <br /> Total fee Due \o <br /> Total Number of Tanks <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check, PAYMENT <br /> RECEIVED <br /> y� 90-103 <br /> EXAM BANK OF STOCKTON 1211 <br /> GOM ME NCI.L 5/.V INGS TNl15T <br /> ETo<KTON G.EI'oFNIA <br /> 20701 <br /> 90FS20N. <br /> CALIFORNIA <br /> UNION ST-,STOCKTONryCALIF.10952091.SA <br /> P.O. BOA 598 STOCKTON,CA,P. 95201-0909 <br /> 'NONE 209/48h0333 kj <br /> 0oDOLLARS <br /> /op <br /> PAY / / G DATE CHECK NO pvyiq 'j <br /> T n oa .aw5 <br /> TO <br /> THE �-sY <br /> ORDER OF V l� STOCKTON SERVICE STATION EQUIP.CO.,INC. <br /> *Both cl ----- <br /> 2-11116 - — <br />