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ren e„tn rHt.lLllr <br /> DBA / fFAC ILITY <br /> /17ADDRESS 017L3V f Agin <br /> MAILING ADDRESS s0 Z /0, / "7 <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ EI5n. <br /> b. Additional Tanks (N Additional Tanks x 850) <br /> 2• State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> (856 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 /> (N_ Temporary closures x 880) (See above N3 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 890) A yG <br /> S. Plan Check Fee 830. <br /> Total Number of Tanks / Total Fee Due -1A °- <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check <br /> Aq Y <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks R eCF L N T <br /> ( I r-equL3r, 1 unleaded , 1 suprem(, , I waste. -Oil ) <br /> EO <br /> a . Exis [inq Facility R 1st Tank SISDk/�0 <br /> b. 3 Additional Tanks x S50 150 �'1,M q <br /> -- PFR r/S��IN�A�rH <br /> 2 . Sta [t' Surcharge , 4 sank; x S5G 224 <br /> Total Number of Tanks 4 Total Fee Due SS?4 <br /> 'Both closures will be conditioned. Contact a Health District Representative. <br /> 2-86 <br /> UC,-7 � ! • • <br />