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DBA � FACILITY <br /> ADDRESS .• <br /> NA MING ADDRESS <br /> I. Operating Permit App' ication/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (I 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 /> 456 x Total N Tanks) <br /> 3• 'Temporary Closure — <br /> (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 /> (N._ Temporary closures x $80) (See above 13 to calculate surcharge) <br /> 4• `Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where the owner/operator has no intent <br /> of re-using tank . <br /> (a 2— Permanent Closures x $90) <br /> PAY&IVES � v <br /> 5. Plan Check Fee 530, RECEIVED L— <br /> I jo <br /> --— <br /> Total Number of Tanks 67-, UNVIRONMENTAL HEALTH <br /> PERF jj4E49E8ue <br /> Make all fees payable to San Joaquin q Local Health District. Enclose this worksheet <br /> with your check <br /> BANK OF STOCKTON 90-103 <br /> caim -CATO ,CALIFORNIA - 121 1 <br /> CALIFORNIA CONTRACTOR LICENSE]0910]C-61,SA <br /> 1108-920 N.UNION ST..STOCKTON, CALIF, 00$09 <br /> P.O. BOX!08 STOCKTCN,CALIF. 99201-0808 19725 <br /> PKONE $09�N48J]] /' <br /> PAY OF(�� _ tW Q�.D 1 K tt/ �/ o!2 <br /> ARS <br /> DATE CHECK NO, <br /> T //�^ `— 1r �/����y {�Y Q7 OOLLJLLARS CENTR <br /> TO THE \ ��.�rTL-l" 1•�I • q- 30 vV I / ! aS /VO D <br /> ORDER OF --�— <br /> STOCKTON SERVICE STATION EQUIP.CO., INC. <br /> t0 <br /> 11.01972511• 1: i2 1 10 10 3 71: 2L1112SO 5Sell 311.0L <br /> tt <br /> 1. -7 7f <br />