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dIILL I f Lh O%Ut rAl,lLI 1 ''- Y <br /> OAA FACILITY <br /> s ADORESS a a �tv Ly <br /> MAILING AOORESS S I <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. ' <br /> b. Additional Tanks (0 Additional Tanks x $50) <br /> 2- State Surcharqe (per tank) (Oue with Permit Application. <br /> on renewal or amendment of operation permit and temporary closure) <br /> (S56 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 /> (I. Temporary closures x $80) (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 , ` r <br /> (I *,:I, Permanent Closures x $90) <br /> Plan Check Fee S30. MAR 1 <br /> Tw <br /> EN R M1T/SER1f CSS <br /> Total Number of Tanks EWAL HEAL <br /> SER <br /> Total Fee Due , DD <br /> Make all fees payable to San Joaquin Local Health Distract. Enclose this worksheet <br /> With your Check <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks r� I <br /> ( 1 regular, 1 unleaded, 1 supreme, 1 wash' oil ) JJ�r '0 <br /> la 1_xistln(I Facility & 1st Tank 5150 <br /> !) 3 Additional Tanks x $50 150 <br /> 1 State Surcharge.-4 Tanks x SSG 214 <br /> Total Number of Tanks 4 Total Fee Due 5574 <br /> 'Both closures will be conditioned. Contact a Health Distract Representative. <br /> 2-136 <br /> Ila-rr� I <br />