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FEE WORKSHEET PER EACH FACIL11 <br /> 1 FACILITY <br /> DBA vN( ON `l- �/V ADDRESS <br /> MAILING ADDRESS <br /> SS o— o <br /> J CI p <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. ��� / 00 ' <br /> 6 <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 and temporary closure) <br /> ($56 x Total k 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 03 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 /> (M Permanent Closures x $90) <br /> 5. Plan Check Fee $30. <br /> 1qPP4T/0.Aveti y�0 0-0 <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 /> PAYMENT- <br /> ----- - - - - - - -- -- R-E-CE1_V_ED__ <br /> .. <br /> SEMCO <br /> EXAMPLE - Annual Fee for TERRY HAMILTON, PRESIDENT <br /> RICHARD C. HAMILTON, V.P. 1365 <br /> ( 1 regular, l PH. 209-5249653 <br /> 431 W. HATCH ROAD I� —� U-19 $� <br /> MFDESTO, CA 95351 90-1314/1211 <br /> b. 3 Addt tlo 1j O'Y11 Tee <br /> la. Existing o' oxocuoF ___ r9 (� �,� �,p�p� <br /> — / _�&zJ $ 700 . 00 <br /> 2. State Sur Q�� G1I <br /> --/6 -- <br /> ION SAFE ---DOL S <br /> UN <br /> Total Number 1 DEPOSIT <br /> 11 IIJ�/ / � asap erwa.,.111dEeCA DA9 A <br /> *Both closures will be cond <br /> 2-aG <br />