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FEE VOF4,.:SHEET <br /> DBA 17 a44W, <br /> f <br /> ADDRESS �Q_-'! f�LJ1,26 3 <br /> 01 <br /> 1: Operating Permit�Application/Annual Inspection Fee <br /> a. Existing Facility and 1st Tank @ $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) <br /> ($56 x Total #-z <br /> v Tanks) <br /> z1 � <br /> 3. Temporary Llosure (per tank) Underground-Srtoragc Tani: ,in, kick <br /> storage has ceased but where the owner/operator proposes to <br /> re-use tank within 2 years, _ <br /> (# Temporary closures x $80) <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 within next 2 years. <br /> (#__Z Permanent Closures x $90) 00 <br /> Total Number of Tanks -ID Total Fee Due _ <br /> Make all fees payable to San Joaquin Local-Health District. Enclose this worksheet <br /> with your check D r= ` <br /> M <br /> MAR <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, lsupreme, 1 waste FSIOMENTAL HEALTH <br /> FrIWAIT/SERVICES <br /> la. Existing Facility & ,Ist; Tank $150 <br /> b. 3 Additionaj Tanks x $50 <br /> 2. State Surcharge, 4 Tanks x $56 D <br /> Total Number of Tanks 4 Total Fee Due $ 2 ,� <br /> H <br /> ENVIR £`� L CES' <br /> F N►Il/5� <br /> *Both closures will be con °tioned. Contact a Health District Repres ntati.ve. <br /> i <br /> 12/85 <br />