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ADDRESS 'I seve'lf�Aj� <br />MAIL[k ADDRESS <br />/ `7�) 7 rCoPve I" <br />1. Operating Permit Application/Annual Inspection Fee <br />a. First Tank at Facility @ $150. <br />b. Additional Tanks <br />( N -t,::`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 />(S56 x Total NZ_ 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 $80) (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 L Permanent Closures x $90) <br />5. Plan Check Fee $30. <br />-6-;.- <br />4 iC2 I <br />Total Number of Tanks -20i0 fSt� '� 9U <br />ake all fees payable to San Joaquin Local Health District. Enclose this worksheet <br />lith your check <br />EXAMPLE -- Annual Fee for Facility with 4 Tanks <br />(1 regular, I unleaded, 1 supreme, 1 waste oil) <br />la. Existincl Facility & 1st Tank <br />1). 3 Additional Tanks x 550 <br />2. State Surcharge, 4 Tanks x 556 <br />Total Numher of Tanks 4 <br />Total Fee Due <br />$150 <br />150 <br />224 <br />5524 <br />PAYMENT <br />REG�IVED <br />��yy]RO <br />PERM; <br />th closures will be conditioned. 'Contact a Health District Representative. <br />0116 <br />a -T .�I <br />_ _ y J <br />~-•-7-r• --i..t: T ur;S Inge+ is - T= �" r <br />