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o . — nu1 CALL <br /> DBA : FACILITY <br /> S i ADDRE1S3 C <br /> MAILING ADDRESS ` • <br /> I• Operating Permit Application/Annual inspection Fee <br /> a. First Tank at Facility P $150. <br /> 2 <br /> b• Additional Tanks (/$ Additional Tanks x $50) �— <br /> State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and <br /> ($56 x Total I � Tanks) temporary closure) <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 /> (1 1'& Temporary closures x $80 <br /> 4• Permanent Closu ) (See above /3 to calculate surcharge) <br /> re (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 /> (M Permanent Closures x $90) <br /> S• Plan Check Fee $30. T,ak e'/csv r, L7a �,C, <br /> Total Number of Tanks <br /> Total Fee Due U <br /> Make all fees payable to San Iuin <br /> with your check . 9 Local Health District Enclose this worksheet <br /> CxAMnfr _ Annuel fns` for- FaciliCv witr; <br /> f <br /> una I i, ri <br /> S Lf Cr ` u rC lia rrvl" . 4 fink <br /> _ 1 <br /> Total NOf TdnkS 4 <br /> .— TOCaI Fee Oue 5574 <br />'Both closures will be conditioned, Contact a l+e <br /> alth District ative, <br />-116 <br /> F-7 a ( • • <br />