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rLL NOROHLLI PER EACH FACILITY /,off7906 <br /> DOA �C . � ,, FACILITY <br /> / "/• �fi" ADDRESSi <br /> MAILING ADDRESS ' <br /> iCRL'l"J:'S7V <br /> �ryC. <br /> I. Operating Permit Applicatiuil/Annual Inspection Fee - <br /> a. First Tank at Facility @ 8150. �`, '•IC -y/,`'r1�1 7Y <br /> b. Additional Tanks (M / 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 /> (856 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 /> (M_ Temporary closures x 880) (See above M3 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 /> (N_ Permanent Closures x 890) -- <br /> 5. Plan Check Fee 830. <br /> Total Number of Tanks � T / 4 <br /> • Total Fee Due // L) <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check . <br /> Koee aTe MAI%ovrm%oeao 11-35/1210 <br /> BANK OF AMERICA <br /> _ %.O.a % Ia3 MooeaTe•c as aa] <br /> SEMCo 6357 <br /> 431 W.HATCH RD. (209)524-9653 <br /> MODESTO,CALIFORNIA 95351 ` <br /> PAY 77 •T '^2 ; is-3Fp DOLLARS <br /> TO THE ORDER OF ,/„ er'� II—�j�— DATE CHECK NO. AMOUNT <br /> Y <br /> - SEMCO <br /> j CCS <br />