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f r _ <br /> `1At�11���RE�S �t <br /> JACILITT <br /> wry_ <br /> + , "� �;;" �4•fy+ ,Lam.-;f�'M ' 4 <br /> 04 �V <br /> dke2mn- U- <br /> 't lire A tib: <br /> r ' <br /> t 4� 1dd1'tt ona)'Maks 1 tj �� ASI c •c�4!.� �', <br /> z,fttae <br /> lor� nt 4f oPeratlonype�'i�if►, I�Ad� p�pgrarr Nasulrej <br /> e <br /> `�t56G IK�•1'o'CalTanks) G <br /> 3. "Temporary Closure (par tank) Undergr xW,$torag9 Yank in which <br /> `itorage his ceased but where the ower/opqr#tor proposes to <br /> ra-use tank within 2 years, # <br /> (f <br /> Temporary ciosuras x $801 (Ste aboY*413 to,'rcalcwlate sur+�fiar <br /> 1"Permaes'itit Closure (per tank) Undtryrouad Sltorage;Tank in which <br /> storage has ceased and where the owner(Qperatar bad ro !)meat <br /> of, re-uting tank . ` ' A <br /> U Permanent Closures x $901 <br /> 3. Plan Check Fee $10. <br /> Total Dumber of Tanks 1 Total Fee Duey <br /> hake all fees parable to San Joa uin Local Health District. Enclose this worksheet <br /> -4lh your Check <br /> PAYMENT <br /> RECEIVED <br /> �AlLi <br /> f I , t <br /> �[A�{'i f Jflllfll t I ( •a' flli F.�c 1 ( � (Y .f a {Rl v I iF1� •► ' <br /> I I r r I f l f I. ,rl ,l , 1 .f,.�f �, . I w.+ • � • " I } ENVIRONMENTAL HEALTH <br /> I : ► k t ,t tiff) S 1`WPERMIT(SERVICES <br /> 1� i • fl f l i un.� I 1 1016 , a $'.iI) t',tl ` <br /> r.' 1?4 <br /> State �h.�r t1f• 4 IdnlS x � ��1 , <br /> F <br /> 101 a l Hunfber of f bnk s 4 ` Iota$ fee (}ue 55?4 <br /> -Both closures will be conditioned. Contact,`y1,�44lih�,0ittrl'rt' Re frts�ntatire. <br />