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fEE NORKSH T PER EACH FACILITO • <br /> CSA l �// FACILITY <br /> Al <br /> 11oDRESS <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 /> (/� Temporary closures x $60) (See above l3 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 /> (d / Permanent Closures x $90) <br /> S. Plan Check Fee $30. <br /> Total Number of Tanks Total Fee Due (� — <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 Tanks �j <br /> ( I regular, I unleaded, 1 supreme, 1 waste oil;} !v Cl <br /> Ia. Existing Facility b 1st Tank $150 7 <br /> b. 3 Additional Tanks x $50 150 <br /> 2, State Surcharge, 4 Tanks x $56 224'' <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> PAYMENT <br /> RIECEIVED <br /> 'Doth closures will be conditioned_ Contact a Health District RepresentaM ve 3 1988 <br /> RONMENTAC HEALM <br /> z-86i frPERMITJSERVICES <br /> uel--7- <br />