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EE ur;*;SiiE£T PER EACH FACILIT <br /> / . : _.T.r <br /> DA ADORES _, . .,. <br /> 4jq11 e <br /> ALINC AOORESS i/ <br /> LCJO/d <br /> 1. Operating Permit Application/Annual Inspection fee <br /> a. First Tank at Facility @ USO. <br /> b. Additional Tanks (I Addition&l•:Tanks.x $50) <br /> t. State Surcharge (per tank) (Due with Pernit Application. <br /> on renewal or amendment of operation permit andtemporary closure) <br /> ($56 x Total I Tanks) <br /> il. "Temporary Closure (per tank) Underground Storage Tank in which <br /> storage has ceased but where the ownerloperator proposes to <br /> re-use tank within 2 years. <br /> (1._Temporary closures x $80) (See above #3 to calculate surcharge) <br />�• •Permanent Closure (per tank) Underground Storage Tank in which <br /> storage hat ceased •and where the owner/operator has no Intent <br /> (/_Q_ Permanent Closures x $90) <br /> 5. an Check Fee $30. <br /> Total Number of Tanks Total Fee Duel O-0 <br /> Make all fees payable to San Joaquin Local Health Oistrict. Enclose this worksheet <br /> with your, check • <br /> EXAMPLE - Annual Fe^ FAe FAcilitV with 4 Tanks <br /> ( 1 regul a Ir- <br /> Ia. <br /> la. Ex i s CHARLES JACOBS 1380 <br /> 13889 W. HWY. 12 <br /> b. 3 Ad gg' LODI, CA 95240 March 15 , gg 90-3907/1211 a <br /> 2. Stat i <br /> San Joaquin Local Health Dist $ 180 . 00 <br /> Total Nun 1 One hundred eighty and no/ 100 ------------ ' <br /> (yam D011AkS <br /> Valk y Commercial Bank <br /> P.O.Wo.%00 <br /> I <br /> A <br /> 1031E.l W.4rbo RoW <br /> tock <br /> 8bn,n,Ctllforni.86208 pfrA <br /> =Goth closures will be 11 -permit for abandonment <br /> 0f <br />