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� fACIL1TY <br /> DBA Ll7e)) �OY1SC iC fF fiF'G 1)isf/1er ADDRESS <br /> MAILING ADDRESS La �S �zk/z <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $150. <br /> b. Additional Tanks (N �T Additional Tanks x $50) <br /> 2• State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total / Tanks) <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 /> (� - 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 , <br /> (N -tom Permanent Closures x $90) <br /> 5. Plan Check Fee S30. <br /> hrevieus Lbrilcince- <br /> (gyp <br /> Total Number of Tanks Total Fee Due a ) (j <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check <br /> EXAMPLE - Annual F.,e for Facility with 4 is k{ J <br /> ( I roqu1ar, I unl �aird , 1 ;u r I wa ,L' oil ) r <br /> la . L. ittinrl T i 5150 <br /> , 1rtiUrrFla I lank , R SS0 <br /> ISO <br /> Z. SCaCP iurchar(lo , 4 tanks x S5o } 224 <br /> Total Number of Tanks 4 p�total Fee Due 5524 <br /> 'Both closures will be conditioned. Contact a Health District Representative. <br /> -116 <br /> C.'--7 j <br />