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.: YOS f£76 <br /> -; <br /> 170 E, XSEMltE <br /> F £' RKSHE£T <br /> WAWA CA 95336 <br /> .. . 1 219- 2n '4399 <br /> DBA ve S <br /> ADDRESS O O <br /> 1. Oper4ting,Pemft Application/Annual Inspection Fee <br /> a. Existing Facility and,. lst Tank @ $150. <br /> b. Additional Tanks (# 2.- Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, 1 <br /> on renewal or amendment of operation permit) R <br /> ($56 x Total # > Tanks) <br /> 3. * mpora~ . Underground Storage Tank in ,.,h41ch <br /> Tc„�;,�, u,y �.ast,re (F�r tat�.� -, .,.. .,.,,,, g� ...�, . ,, ��„,�„ <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, a' <br /> (# Permanent Closures x $90) _ - <br /> Total - Number of Tanks ` Total Fee Due <br /> ,Make all fees payable to San Joaquin Local Health District. Enclose -.thit worksheet <br /> with your check NNW <br /> g <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> (1 regular, 1 unleaded, 1 supreme, 1 waste oil ) <br /> la. Existing Facility & 1st Tank $150 <br /> b. 3 Additional Tanks x $50 150 <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> Total Number of Tanks 4 Total Fee D�f`iC, j <br /> t <br /> E8 i 06 <br /> r <br /> *Both closures will be conditioned. Contact a Health District Represent ive. <br /> HEAL <br /> 12/85 <br /> FERMIT/ACES 1H <br />