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+r; <br /> RKSHEET PER EACH FACILITY 6FACILITY <br /> Q e ADORE S /S G /Gilf <br /> G ADDRESS , I <br /> rating Permit Application/Annual Inspection Fee <br /> First Tank at Facility N $150. <br /> Additional Tanks (N Additional Tanks x $50) <br /> tate Surcharge (per tank) (Due with Pemit Applications <br /> n renewal or amendment of operation permit and temporary closure) <br /> $56 x Total N Tanks) <br /> emporary Closure (per tank) Underground Storage Tank in which <br /> torage has ceased but where the owner/operator proposes to <br /> e-use tank within 2 years. y ;: <br /> (/_ Temporary closures x $80) (See above 13 to calculate surcharge) <br /> ermanent 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 _ ��U <br /> (lam Permanent Closures x $90) <br /> Ian Check Fee $30. <br /> �' Total Fee Due � <br /> Total Number of Tanks ; <br /> all fees Payable to San Joa uin LocalHealth District. Enclose this worksheet <br /> hyour check , «_m_s_m_—_u_—_u_d_—_—_—1 <br /> SEMCO / 191 <br /> TERRY HAMILTON - PRESIDENT _`�lE..-__ I'+ <br /> I RICHARD C. HAMILTON - VICE PRES <br /> 431 W. HATCH RD, <br /> PH. 524-9853 v v <br /> JS/121 <br /> E ZFP1�t[ 1 MODESTO, CA 95351 <br /> 4 <br /> 1 Bank of America' {� <br /> Modoslo Main 01hu 0030 <br /> iPO. Box. lag <br /> Modosto,CA 95353/T��.y.,,��L •`//]�`% � � <br /> ' nil mmol <br /> _.,._.,._,.._.,,_—_.._ <br /> th closures will be conditioned. Contact a Health District Representative. <br /> YL <br />