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ILL PER EAC11 tALILI <br />Q.A.• FACILITY <br />AooRESS <br />MAILING ADDRESS L <br />I - Operating Permit Application/Annual In0ection Fee <br />a. First Tank at Facility $ISO. <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 />M6 x Total M 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 />(1 Temporary closures x S80) (See above 13 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 />(I -?,Permanent Closures x 190) '`k- v <br />S. Plan Check Fee S30. <br />Total Number of Tanks <br />d <br />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 <br />(1 regular, I unleaded. 1 supreme. <br />la. Existing Facility b 1st Tank <br />b. 3 Additional Tanks x 150 <br />2. State Surcharge. 4 Tanks x 156 <br />Total Number of Tanks 4 <br />1 waste oil) <br />SISO <br />ISO <br />.. 224 <br />Total Fee Due, $524 <br />•00th closures will be conditioned Contact, a -Health District Representative. <br />2-116 <br />('14 <br />