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fACILITY 2 O <br /> OBA ADDRESS <br /> MAILING ADDRESS . <br /> 1. Operating Permit Application/Annual Inspection Fee1 . <br /> �� a <br /> a. First Tank at Facility @ $ISO. /s <br /> b. Additional Tanks (lam_ Additional Tanks x 150) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> (156 x Total I / 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 /> (/_ Temporary closures x 180) (See above M3 to calculate surcharge) <br /> 4. "Permanent Closure (per tank) Underground Storage Tank in which <br /> storage has ceased and where the Qwner/operator has no intent <br /> of re-using tank, 9D <br /> (I( Permanent Closures x 190) <br /> S. Plan Check Fee 130. <br /> Total Number of Tanks Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. <br /> PAYMENT <br /> RECEIVED � `� <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks AU G v 1�'" <br /> ( I regular, I unleaded, 1 supreme, 1 waste oil ) ENVIRONMENTAL HEALTH <br /> Ia. Existing Facility b 1st Tank $150 PERMITISERVICES <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge. 4 Tanks x S56 224 <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> `3 *Both clot' S will be=conditioned. Contact a Health District Represeot5tive <br /> u <br /> "\(✓z • `h(P�4,f d� '' .ti 2.FkE. 4 ` i i}4 -," f1a: <br />