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FEE yQRKSHEET PER EACH FACILITY <br />�) FACILITY <br />ADDRESS <br />,MAILING <br />1. <br />2. <br />3. <br />4. <br />M <br />0 <br />. Cid C 7e—,0 <br />Operating Permit Application/Annual Inspection Fee <br />a. First Tank at Facility @ 115Q. <br />b. Additional Tanks (I Additional Tanks x $50) <br />State Surcharge (per tank) (Due with Permit Application, <br />on renewal or amendment of operation permit and temporary closure) <br />(156 x Total I Tanks) <br />"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 />0— Temporary closures x $80) (See above 13 to. calculate surcharge) <br />*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 />Permanent Closures x $90) <br />Plan Check Fee $30. <br />Total Number of Tanks / Total Fee Due <br />0 <br />P <br />Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br />with your check. <br />PAY <br />FRAENANCE <br />NLiEOUIPMENTECO. <br />1450 COLUSA AVE. 916-673-9253 <br />YUBA CITY. CA 95991 <br />%NE <br />W <br />SUTTER BUTTES SAVINGS <br />AND LOAN A990CIATION <br />l00 Plumu Bva.l•P.O.�. Vso.YUE. CIp,CA 86B9P <br />FOR �t—" rC� i ✓ <br />9'00101411■ 1:32Lla1255t: <br />2 30 L8 2600911' <br />1014 <br />9061T" <br />3211 <br />DOLLARS <br />