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t[E NuRKS1(GLl PER EACH FACILITY <br /> FACILITY <br /> DBA ADDRESS <br /> MAI LI N,G•ADDRESS <br /> 1. Operating Permit Application/Annual Inspection Fee <br /> a. First Tank at Facility @ 1150. �F _ <br /> b. Additional Tanks (/ Additional Tanks x $50) <br /> 2. State Surcharge (per tank) (Due with Permit Application, <br /> on renewal or amendment of operation permit andtemporary closure) i <br /> ($56 x Total I ' 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 13 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, S3:)1M3Sj11W113d 90 ,0o <br /> (IPermanent Closures x $90) jWV3H 1d1NM0111ANI <br /> 5. Plan Check Fee $30. 8M Q <br /> 1TIAWA!i!o al Fee Due <br /> Total Number of Tanks <br /> Make all fees payable to San Joaquin Local Health District. Enclose this worksheet <br /> with your check. <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> <br /> *Bot <br /> LII 23 032 2/86 <br />