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t HLILIIi <br /> 6A yfA e ctrl .strQ C poJ ADDREss ljyorK e <br /> RILING ADDRESS 0• ' 8-ax 3no3 S I Sf/(hJ <br /> Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (/ Additional Tanks x $50) <br /> State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit andtemporary closure) <br /> (S56 x Total I Tanks) 8(0 <br /> 'Temporary Closure (per tank) Underground Storage Tank in which / U <br /> storage has ceased but where the owner/operator proposes to —150 <br /> �8 <br /> re-use tank within 2 years. � W 7,91O(C' <br /> (1_ Temporary closures x $80) (See above t3 to calculate surcharge) <br /> `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. p4yMFN7 <br /> CjD <br /> (/ REGBIVED <br /> _ Permanent Closures x S90) / <br /> Plan Check Fee $30. oc1 ., ' 1�d8 <br /> ENVIRO IlCES <br /> ENTAL HEALTH / <br /> PERM <br /> Total Number of Tanks Total Fee Due 15 Fc ' <br /> 14 300 <br /> ake all fees payable to San Joaquin Local Health District. Enclose this worksheet 90 pd lb�7&F <br /> i th your check. 31/Fe <br /> — ---- — - -l-P--- -- <br /> UNION SAFE DEPOSIT BANK 90=108 3782 <br /> ROEK BROTHERS STOCKTON,CALIFORNIA 1211 <br /> P.O.BOX 30038 :DATE - CHECK NO -AMOUNT <br /> STOCKTON,CALIFORNIA 95213-0038 <br /> 10-31-88 3782 $210 . 00 <br /> I <br /> PAY <br /> TO THE San Joaquin y�► <br /> ORDER TION Local Heal2 i 0 6l1 <br /> 0 0l <br /> ,(O/Ifa'Gl� /ski <br /> - -- A-Si SIGNA'MR15 UR <br />