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LA LAW tALI <br /> n ' DBA �/livt /rmnr. � ✓ FACILITY <br /> v✓not✓�rvFvl �591G ADDRESS <br /> MAILING ADDRESS <br /> � FQ� <br /> i• Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facilitv @ $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 /> (E56 x Total /� 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 s80) (See above /3 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 /> (N / Permanent Closures x Ego) <br /> T vk <br /> 5. Plan Check Fee $30. — <br /> �mvidu.� <br /> Total Number of Tanks _Q <br /> Total Fee Due f �O <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 T,jnk•, <br /> ( 1 re0ul4r , I unloaded , 1 ;upreni •, I w.t . ir• ;i1 ) <br /> V <br /> la . Extstinq F4Ciltty g Ist Tenl JS150 <br /> b. 3 :.drlttional T,tnk•, , SSD <br /> r• State Surchar r ,- 4 -Tanks U 1 �0 <br /> 9 x S56 � ,224 <br /> $5 <br /> Total Number of Tanks 4 (f� <br /> — Tot a I ,F�, $524 <br /> *Both closures will be conditioned, Contact a He C/J <br /> alth District Representative. <br /> -86 <br /> C-7 .7l • • <br />