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fEE WORKSHM PER EACH FACILIT <br /> n / FACILITY q // <br /> DBA `J,6, W ADDRESS <br /> MAILING ADDRESS_ �3�a l �✓' rI�/rI l 2, '0A o <br /> I. Operating Permit Application/Annual Inspection Fee ^ W <br /> a. First Tank at Facility @ $150. /SD /5"0 <br /> b. Additional Tanks (I Additional Tanks x $50) �—o Sb <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 M y Tanks) / /Z <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 I3 to calculate surcharge) <br /> 4• `Permanent Closure (per tank) Underground Storage Tank in which <br /> / <br /> storage has ceased r and where the owner/operator has no intent <br /> of re-using tank , <br /> ( A_ Permanent Closures x $90) <br /> 5. Plan Check Fee S30, e6 4 7 <br /> Total Number of Tanks L Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check , <br /> IXAMPIE - Annual Fee for Facility with 4 Tanks <br /> ( I regular, I r- 1 <br /> la . Fxistini 1 CHARLES J � � � <br /> i Aco1379 <br /> h. ] Add it 13889 W. HWY. 122 <br /> LODI, CA 95240 <br /> 2 . State S March 15 , iegg 9o-3907n211 <br /> San Joaquin Local Health <br /> Total Number Five llist $512 . 00 <br /> @ <br /> hundred twelve and no/10o-----_-- <br /> Valley Commercial Bank — x n i Ak, <br /> P.O.1031 E.t Boa 9700 <br /> *Doth closures will be co <br /> Sbikbn,C.11f..W-Wd.952" , <br /> 2-ISL <br /> y <br />