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FEE WORKSHEET PER EACH FACILITY .r. 4< <br /> DBA PO -r U f S70 vlk70 +� ADORES S FACILITY �- V`� G�o'sZs <br /> d1� <br /> 1 <br /> MAILING ADDRESS 1 O d 7< rcf /`N ZO <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. S� 1�0 <br /> b. Additional Tanks (f Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit ApplicationE, <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total NTanks) <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 /> 0 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 gwner/operator has no intent <br /> of re-using tank. <br /> (I Permanent Closures x $90) <br /> 5. Plan Check Fee $30. <br /> Total Number of Tanks Total Fee Due 906 <br /> - <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. <br /> FPe__fnr Faci 1 i ty with 4 Tanks <br /> TNI.cMccw e.o[uvewco row prM[NT -- <br /> ONTM[rOLLOWW6ACCOUNT.I •�—`�.— —__.`.�. <br /> RICH-MART <br /> JIM THORPE. DISTRIBUTOR OF QUALITY PRODUCTS 10230 <br /> 368-6175 462-4581 <br /> 351 NO. BECKMAN ROAD, P.O. BOX 357 <br /> LODL CA 85241-0357 IMM211 <br /> PAY <br /> • TOTAL TO TH E <br /> 1 ORDER OF <br /> OI/COUNT _ Qi ^ O� <br /> VNT OF CHECK aD �V•L/. <br /> DOLLARS <br /> LOUT OFFICE <br /> 126 W.Walnut 5t.•Lod$,CA 95M <br /> A � <br />