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_ ILLI PLIf LAW I-ALILIC. '. <br /> ,A' (,�,,�.�n �� FACILITY <br /> I'l ADDRESS /ILD <br /> ADDRESS S/)4 f" <br /> tn�ke�M{-�plii� �'f �a a t�•r � t sails� 4 � �F� � "7:` 3Fi 3, <br /> Aerating-}.Pe,rmit cation/Annual4nsp�ctton'�FeegG 1 <br /> Ap ; <br /> A. First Tank at Facility `N Sl50'- <br /> . ry. <br /> b. Additional Tanks (f Additional Tanks x $50) <br /> State Surcharge (per tank) (Due with Permit Application,-:016(- <br /> on <br /> pplication;°916(- <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total M 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 owner/operator hps no intent <br /> of re-using tank, b o9 I <br /> (/ I Permanent Closures x $90) �� 2L1 (� /l•lC <br /> 5. Plan Check Fee S30. <br /> Col 166 3 L <br /> VW <br /> Total Number of Tanks � Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check , <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> ( t rPnular 1 nnlmAoA 1 I ,.aa In <br /> RICH - MART 10032 <br /> JIM THORPE, DISTRIBUTOR OF QUALITY PRODUCTS <br /> - 368-6175 462-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 <br /> 90-107 <br /> LODI. CA 95241-0357 / 1211 <br /> PAYTuTIL <br /> TOTHE N •_I ` Ga. LIL` $ �/ �// <br /> , I osco...+ Ili i ORDER OF !'-- a' <br /> DOLLAR? <br /> E <br /> o. « i. i ✓j C <br /> Or <br /> BANK of STOCKTON <br /> LODI OFFICE <br /> 120 W.Walnut St.,Lodi,CA 95240 <br /> 2 <br /> 06 11'01003 2114 1: 1 211010371: 23-00197GOD I <br />