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{ <br /> F \ <br /> 06A' � ems— ur�nee nnDRESS <br /> MAILING ADDRESS �' i <br /> 16 F- CIA 4'3-71 p <br /> I• Operating Permit Application/Annual Inspection Fee —1-�` <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (I I Additional Tanks x $50) Imo_ r <br /> 2• State Surchar e ��- 5U <br /> g (per tank) (Due with Permit Application. <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total I Z Tanks) II 2 <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 /> (I_ Temporary closures x $80) (See above 13 to calculate surcharge) <br /> tell <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 /> (I_ Permanent Closures x f90) <br /> 5. Plan Check Fee $30. <br /> Total Number of Tanks _ Z= <br /> Fee Due N X12 � 200 " 20,u <br /> Total Pc e_ bue = u�l 12- <br /> Make <br /> 2-Make all fees payable to San Joaquin Local Health District Enclose this worksheet <br /> with your Check <br /> FXAMPL� _ Annual Fee for Facility with 4 Tanks <br /> ( I rt,gular, I unleaded, I supreme , I w,iste oil ) <br /> la . Existing Facility S I s t Tank $I50 <br /> Ir. <br /> 3 Additional Tanks x $50 ISO <br /> 2. State Surcharge , 4 Tanks x $5G <br /> -- 224 C' .a v hl E iV T <br /> r; f:.CE1VED <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> r -t, IU �- <br /> LNVIRO h1 T`�TAA EESALTH <br /> P <br /> 'Both closures will be conditioned, Contact a Health District Representative. <br /> 2-RG <br /> ''j(37 .71 <br />