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tLL W'WW)HLLIPER EACH FACILITY <br /> D3A �og A Nci so FACILITY n <br /> ADDRESS 1 -790S `"OMOI)k)EX (/IANZE-QA <br /> MAILING ADDRESS 3nU �DAt/ c. 0 . Lelj �ib 4- 4 <br /> 323 9ELAA0A1j C/a 91 (4002 <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (N 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 /> (S56 x Total N 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 I Temporary closures x $80) (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 /> PAYMENT <br /> (N_ Permanent Closures x $90) RECEIVED <br /> 5. Plan Check Fee $30. <br /> ENVIRONMENTAL HEALTH <br /> Total Number of Tanks <br /> B PERMIT/Sf&�/AqEj7ee Due <br />} Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> ( 1 regular, 1 unleaded , 1 supreme, 1 waste oil ) <br /> Ia. Existing Facility 8 1st Tank $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge,-4 Tanks x $56 224 <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> 'Both closures will be conditioned. Contact a Health District Representative. <br /> 2-86 <br /> OTT- <br /> .� r <br />