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L� tACN FAC ILiT <br /> DBA ,n MN pTY <br /> � re FACT L I TY <br /> MAILING ADDRESS ADDRESSi/l S <br /> 191V C"I <br /> I• OperatingC 9$-20-� <br /> Permit APFlication <br /> a• First Tank /Annual Inspection Fee <br /> at Faci 1 it,v @ $I5r). <br /> b• Additional Tanks (, Additional Tanks x $50 <br /> State Surcharge � <br /> 9 (Per tank) (Due with Pe �~- <br /> rmit Application, <br /> on renewal or amend j <br /> int of operation permit <br /> ($56 x Total <br /> 3• `Temporary #--J_ Tan ks) and temporary closure) <br /> lo (per tank) Underground <br /> storage has ceased blit where g ound Storage Tank in which <br /> the <br /> re-Use 0"A-r/onerafn�r nroposes to <br /> tank within 2 years. <br /> ` Temporary Closures x $80J <br /> 4' *Permanent Closure (See above #3 to calculate su:'cha <br /> (Per tank) Underground Storage T r9e) <br /> storage has ceased and where the owner/operator has o lin which <br /> of re-using tank. <br /> tent <br /> (# Permanent Closures x $90) <br /> 5. Plan Check Fee $30• y <br /> a c <br /> Total Number of Tanks 7 �� 061/ <br /> Total Fee Due <br /> Make all fees ��-- <br /> payable to San Joa uin Local Health District. Enclose this worksheet <br /> with your check <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> � I regular, I unleaded, 1 supreme, 1 waste oil ) <br /> Ia. Existing Facility & Ist Tank <br /> b. 3 Additional Tanks x $50 $150 <br /> z State Surcharge, 4 Tanks x $56 150 <br /> 224 <br /> Total Number of Tanks 4 --- <br /> - Total Fee Due $524 <br /> C��V1�Ka, �,p�1�.aCt u ��.d1th D1StriCt Re re�sen�.at;ve. <br />