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FARKSHCET PER EACH FACILITY <br /> DBA ( 1�2�t ph�- ���7-� ADORESSY <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 $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 Qwner/operator has no intent <br /> of re-using tank, MENTO <br /> 0 2Permanent Closures x $90) REG <br /> sx <br /> S. Plan Check Fee $30, 13 19 8 <br /> \105 <br /> RE <br /> Total Number of Tanks Total Fee Due / <br /> Make all fees pay — ----L.,nuin Local Health District, Enclose this worksheet <br /> with your check, <br /> TERRY <br /> SEMCO <br /> 6 HAMILTON - -- <br /> F RI CHARD C.LHAMIL RESIDENT <br /> PH. 2og-524-9653 V.P. <br /> O W' HATCH 1325 <br /> f� <br /> EXAMPLE - Ar ,.P "y ro THE MPESTor CA sI [I <br /> ANDER O <br /> dPj 19 <br /> NION <br /> / DEPOSIT o L L <br /> —--- <br /> MEMO % d&ZJ 0, (Q' Y�91id BANK jl <br /> �� <br /> 4i- //[fes <br /> � ;a <br /> ..rte <br /> e.V Ei <br /> ' Ffr <br /> r♦_V <br /> "Both closures will be conditioned. Contact a Health District Representative. { <br /> 2-R6 <br />_IAC-,'7 <br />