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FACILITY <br /> ADDRESS �l.��- S. �,;� S� • �_d; 9f,zvo <br /> MAILING ADDRESS % 1 F <br /> • �O <br /> C A of SZ�co <br /> S <br /> I Operating Permit <br /> Application/Annual Inspection fee <br /> first Tank at ficility P SISI. <br /> b. Additional Tanks (/ Additional Tanks x $5o) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment ,PAYMENT <br /> of operation permit and temporary closure ECSjVED <br /> (156 x Total Tan/ Tanks) <br /> 3. "Temporary Closure ,UL <br /> 2� 19�� <br /> (per tank) Underground Storage Tank in which <br /> storage has ceased but where the owner/operator �RONMENTAL HEALTH <br /> re-use tank within 2 years. proposes to pEVAITISERVICES <br /> (N— Temporary Closures x $80) (See <br /> 4• 'P .above 13 to calculate surcharge) <br /> ermanent Closure (per tank) Underground Storagea Tank in which <br /> storage has ceased and where the owner operator etas no intent <br /> of'`°re-using tank , <br /> (N Permanent Closures x 190) Qn. <br /> S. Plan Check Fee 530. <br /> Total Number of Tanks <br /> Total fee Due <br /> Make all fees payable to San Joaquin local Health District Enclose this worksheet <br /> with your cheCk <br /> • <br /> ExnMrT � A......, T for• FaCillty with 4 T,tnt. . <br /> I r'1•f:u l.l r. I un l r•,t od ) <br /> )II <br /> 1.1. E. ISTIfIfT ( .1t 111 ' x' i I%t T.jnL <br /> S(atl• SurCh.trgr 4 lank,, x S5f) <br /> Total Number of Tanks 4 Total <br /> — Fee c Duc 5524 <br /> Both closures will be conditioned,. Contact a Health District Re resen <br /> _p tative. <br /> -116 <br />