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1�QAKJIiLL i eLk LAIN IALILl "0 <br /> FACILITY <br /> DBA ADDRESS <br /> MAILING ADDRESS <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (p g— Additional Tanks x $50) DO D O <br /> 2• State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> 456 x Total N 3 �Tanks) . od <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 /> R 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 owner/operator has no intent <br /> of re using tank , r <br /> R Permanent Closures x $90) Pq y <br /> MINT <br /> 5. Plan Check Fee $30. REC'EIVE'D <br /> APR <br /> Total Number of Tanks ' SME EAMI �� DD <br /> Due <br /> RVICES,' <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. <br /> A4 b <br /> EXAMPI r <br /> PETER W. ALLEN 134 <br /> LIC. 87811787 <br /> 4724 HIXON CIRCLE 485-4142 Q <br /> SACRAMENTO, CA 95841 . <br /> PAY TO THE $ SOS Ov <br /> ORDER OF_ --- <br /> i L <br /> DOLLAR s <br /> a <br /> SAVINGS <br /> BANK <br /> 1545 River Pads Chive <br /> *Q o t h c l o s _ Swfurienoo,califomla 95815 <br /> 2-86 <br />