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RKSHEET PER EACH 'AC""fA FACILITY � <br /> ADDRESS <br /> �( n r <br /> LING ADDRESS �e 2,� ��� • c c , <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (1 Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit andtemporary closure) <br /> (156 x Total Y 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 /> (l_J_ Permanent Closures x $90) <br /> 5. Plan Check Fee $30. C <br /> Total Number of Tanks Total Fee Due <br /> c �o1�o <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check, PAYMENT <br /> RECEIVED <br /> EXAM BANK OF STOCKTON 90-103 <br /> •Ruw�uvw<s TwusT 1211 <br /> csrocxsoN,uuw ownu <br /> 20701 <br /> GLIFORNiA CONTRACTaY YCEN<AUP059S1'1SA ' <br /> 0000311 N.UNION 9T.,STOCX'fOF. 9 5 20 1-010 0 <br /> P.O. ,Z"/ STO33 CLLI <br /> PXON6 209/<04031] <br /> 1 / o/ LARS <br /> PAY �V I O�T2� <br /> DATE CHECK <br /> cenIs <br /> ��N, <br /> TO TIE 9-Al 513 cvo / D, <br /> ORDER OF� Z4 �dUkL <br /> STOCKTON SERVICE STATION EQUIP.CO., INC. <br /> *Both cl <br /> 2-:1G <br /> T- 11'02070111' 1: 10 10 10371: 2L111250S ' <br />