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` E NORKSHLET PER EACH FORA <br /> FACILITY �/ <br /> A ` ur' �or�t 2vc Pro�� � 24 ADDRESS- /OS01hll 119tr ✓�oua �% / Orh-7-1c� <br /> AILING ADDRESS <br /> - P A'y <br /> RECEIVED <br /> Operating Permit Application/Annual Inspection Fde J U L 12 1986 <br /> a. First Tank at Facility @ $150.. <br /> b. Additional Tanks(/ Additional Tanks,x $5D)„ ENVIPONMiS R LTH <br /> State Surcharge (per tank) (Due with Per mit "Applieati'on. <br /> on renewal or amendment of operation permit and temporary closure) <br /> ($56 x Total N Tanks} <br /> *Temporary Closure (per tank) Underground Storage Tank in which <br /> storage has ceasbut wher&,-the owner/operator proposes`to <br /> ed <br /> re-use tank within 2 years. <br /> (0 Temporary closures x $80) (See above l3 to calculate surcharge) <br /> "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 /> (dam Permanent Closures x $90) <br /> P1 an, Check Fee $30.• 3. 0 •a 0 <br /> Total Number of Tanks ' Total Fee Due ©.OU <br /> 3+ <br /> ke all fees payable.to .San Joaquin Local Health District. Enclose this worksheet <br /> th your check , <br /> EXAMPLE - Annual Fee;for Facility with 4 Tanks <br /> ( l reg6lar ;1 unleaded, I supreme, 1 waste oil ) 4 <br /> la, Existing Facility S 1st Tank 5150 <br /> b 3 Additional<Tanks ;z $50 150 <br /> 2. State 'Surcharge;"4 Tanks x b56 224 <br /> Total NumbW of Tanks 4 Total Fee Due $524 <br /> �resentative. <br /> )th 'ciosures will bre conditioned. Contact 'a Health' District R <br /> a <br /> 1 <br /> s . y <br />