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DBA FACILITY <br /> � :�-t- ADDRESS <br /> MAILING ADDRF S 3 IA <br /> I. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ $15A, <br /> b. Additional Tanks (0 Additional Tanks x $50) <br /> 2. State Surcharqe (per tank) (Due with Permit Application, <br /> an 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 />-`' (N 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 . � .-f a <br /> (# Permanent Closures x $90) C� <br /> 5. Plan Check Fee $30. lynlcn..�( Wd Z41e.CCMi arl &4-L 2 fiu 3 a <br />,dl <br /> I Total Humber of Tankso� <br /> Total Fee Due <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check , <br /> :lz � <br /> EXAMPLE - Annual Fee for Facility with 4 Tanks <br /> ( 1 regular, I unleaded, 1 supreme, J:C iWou,.0'AL HEALTH <br /> Ia. Existing Facility & 1st Tank VER'Y1I1/SERVICEi150 <br /> b. 3 Additional Tanks x S50 ISO <br /> 2. State Surcharge, 4 Tanks x $56 224 <br /> Total Number of Tanks 4 Total Fee Due $524 <br /> *Both closures will be conditioned. Contact a Health District Representative. <br /> Z-8,6 <br />