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u ? -3 - d 3 <br /> ung 41 a ACAWLI IT <br /> MAILING Cl <br /> ADDRESS ADORE S S00 N• Un �or) �ec0. <br /> F � I a <br /> e C a 533 <br /> 0Peratfn9 Perm tl MPUcetl ;� 86 187 �S <br /> a lllnnwl tnapettlonjee f^ g r s <br /> a, :First Tank'at"FactlfEv P E150;' as r— owrtcf <br /> b. Additional Tanks (/� �60t fo Of c, $7 �SO 0Q <br /> Addi _ <br /> 2 St <br /> Additional Tanks x f50) � */Cese <br /> State Surcharge- (Due with PermitSLQ <br /> Applicati t e- -S <br /> on renewal <br /> or amendment of operation permit and teaporary closure) <br /> (156 x Total / 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 /> (/— Temporary closurer.x S80 <br /> JA' Permanent' Chis re •r '' ) (See above /3 to calculate surcharge) <br /> e (Per tank) Underground Storage Tank in which <br /> storage has ceased and where <br /> ;�of; the ownertoperator has no intent <br /> ;re-using=tank; <br /> (/ Permanent Closures x $90 <br /> S• Plan Check Fee S30. ) U-0fl Q- <br /> Total Number of Tanks <br /> Total Fee Due 3q C) 0 <br /> Make all fees payable to San Joaquin <br /> with local <br /> Your Check . Health District Enclose this worksheet <br /> i <br /> E1(AMPT( - Annu•tl Fre fnr' fac111ty wtth T.v1t.•, <br /> ( I r'rr,,; i .tr' . I unlr,lL•q . 1 ,u?r,•r.i" I �'.i'• ; • n 1 ) <br /> le . C . , tt ,n,l Id, , ! , • r • <br /> S1 ')O <br /> I, <br /> Stet,• ISO <br /> Surf hergr' 4 Idnks . S5(1 <br /> 774 <br /> Intal Number of Tanks 4 <br /> — Total fee Due 5574 <br />'Both Closures will be conditioned. <br /> Contact a )+ealth District ReprEsentative <br /> 2-BG <br />