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ttt WOROHLLI PER EACH FACILIT <br /> DBA `/ FACILITY <br /> 7G^Ync i + tii ADDRESS S 7 (r Y /7 pi✓ L h er int( <br /> MAILING, ADDRESS <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (# 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 /> ($56 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_ Temporary closures x $80) (See above b3 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 /> (# x Permanent Closures x $90) �Po 03 <br /> 5. Plan Check Fee $30. <br /> Total Number of Tanks 112— Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check , <br /> $150 <br /> 150 <br /> MAR 51986 224 <br /> AER <br /> MENTA HEALTH �e Due $524 <br /> RVICES <br /> ict Rgresentative. <br /> 2-86 <br />